NOT FOR PUBLICATION WITHOUT THE
APPROVAL OF THE APPELLATE DIVISION
This opinion shall not "constitute precedent or be binding upon any court."
Although it is posted on the internet, this opinion is binding only on the
parties in the case and its use in other cases is limited. R.1:36-3.
SUPERIOR COURT OF NEW JERSEY
APPELLATE DIVISION
DOCKET NO. A-4669-14T4
CARRIER CLINIC-PATIENTS
A.M. and C.I.,
Petitioner-Appellant,
v.
DIVISION OF MEDICAL
ASSISTANCE AND HEALTH
SERVICES,
Respondent-Respondent.
____________________________________________
Argued April 6, 2017 – Decided September 13, 2017
Before Judges O'Connor and Whipple.
On appeal from the Department of Human
Services, Division of Medical Assistance and
Health Services.
Walter J. Fleischer, Jr., argued the cause
for appellant (Drinker Biddle & Reath LLP,
attorneys; Mr. Fleischer, of counsel and on
the brief; George H. Kendall and Andrew C.
Egan, on the brief).
Mark D. McNally, Deputy Attorney General,
argued the cause for respondent (Christopher
S. Porrino, Attorney General, attorney;
Melissa H. Raksa, Assistant Attorney
General, of counsel; Kay R. Ehrenkrantz,
Deputy Attorney General, on the brief).
PER CURIAM
Petitioner Carrier Clinic appeals from a April 29, 2015
final decision of respondent Division of Medical Assistance and
Health Services (Division), which denied Medicaid benefits for
services petitioner rendered to two of its patients, A.M. and
C.I. We remand for further proceedings.
I
The pertinent facts are as follows. Petitioner provided
inpatient psychiatric treatment to A.M. and C.I. Each patient's
health insurance carrier declined to provide coverage for
certain periods of each patient's hospitalization, claiming such
hospitalization was not medically necessary. Petitioner sought
an internal review of each decision by each patient's insurance
carrier, but to no avail. The coverage petitioner sought was
$6,327.75 for one patient and $40,851.40 for the other.
Petitioner did not seek a review of the insurance carriers'
determination by the Department of Banking and Insurance (DOBI).
See N.J.A.C. 11:24A-3.6. This regulation provides an insured or
the medical provider may appeal an internal adverse benefit
determination to DOBI; there are some exceptions to the right to
appeal, but none existed here. Rather, after the internal
2 A-4669-14T4
review within each patient's insurance carrier had ended,
petitioner filed a claim with the Division in 2009 for Medicaid
benefits for the subject uncovered medical bills.
In 2012, the Division sent petitioner a letter stating it
would provide Medicaid benefits for one of the patients for some
of the period of his hospitalization his insurance company
refused to cover, but the Division declined to provide any
benefits for the other patient. The Division declined full
benefits to both on the basis the provider failed to show
medical necessity for the treatment. The Division did not cite
the petitioner's failure to appeal the insurance carriers'
adverse determinations to DOBI as a basis to deny benefits, and
never mentioned such oversight during the period these matters
were under the Division's review.
In response to the Division's determination, petitioner
submitted a request to the Division for a Utilization Review
Fair Hearing on behalf of each patient. Each request was
transmitted to the Office of Administrative Law for a hearing as
a contested matter; subsequently, the matters were consolidated.
Both parties moved for summary disposition. In its moving
papers, the Division asserted for the first time that petitioner
was ineligible for Medicaid benefits because it had failed to
appeal the insurance carriers' adverse determinations to DOBI.
3 A-4669-14T4
On January 30, 2015, the Administrative Law Judge (ALJ)
issued an initial decision granting the Division's and denying
petitioner's motion for summary decision. The judge found,
before seeking Medicaid benefits, petitioner should have but did
not exhaust available administrative challenges to the insurance
carriers' determination there was no medical necessity for the
subject treatment. Among other things, the judge stated:
N.J.A.C. 10:49-7.3(b) states that, "Medicaid
. . . benefits are last-payment benefits."
This presupposes that administrative appeals
as to the [insurance carriers'] liability
would be exhausted before Medicaid is
expected to make payment. . . .
That is not to suggest, as petitioner
claims, that petitioner would be expected or
required to sue or appeal the insurance
carrier all the way to the U.S. Supreme
Court ad infinitum, if need be. Rather, it
is to expect that all administratively
available appeals of the adverse
determination are exhausted before last-
payment benefits are implicated. . . .
The ALJ then noted the binding impact of a decision by an
independent utilization review organization [IURO], such as
DOBI:
To that end, N.J.A.C. 11:24A-3.6(j)(2)
provides that, "The IURO's determination
shall be binding on the carrier and the
covered person, except to the extent that
other remedies are available to either party
under State or Federal law. The carrier
shall provide benefits (including payment on
the claim) pursuant to the IURO's
4 A-4669-14T4
determination without delay, regardless of
whether the carrier intends to seek judicial
review of the external review decision,
unless there is a judicial decision stating
otherwise."
In other words, this appeal constitutes the
final administrative action with regard to
the carrier's determination of medical
necessity, not the . . . internal review.
On April 29, 2015, the Division's director issued a
decision adopting the ALJ's recommendations, stating:
Medicaid is a payer of last resort.
N.J.A.C. 10:49-7.3(b). Each state
administering the Medicaid program is
required to take measures to find out when
third parties are legally obligated to pay
for services covered by the plan. 42 U.S.C.
§ 1396a(25)(A). Once the probability of
third party liability exists, "the agency
must reject the claim and return it to the
provider for a determination of the amount
of liability." 42 C.F.R. § 433.139(b)(1).
Accordingly the ALJ correctly found it
reasonable to expect that all
administratively available appeals of the
adverse determination are exhausted to
determine third party liability before last-
payment benefits are implicated.
This appeal ensued.
II
On appeal, petitioner's principal contention is the
Division erred by denying Medicaid benefits on the ground
petitioner failed to administratively appeal the insurance
carriers' decision to decline coverage. Petitioner argues it
5 A-4669-14T4
complied with the Division's regulations before seeking Medicaid
benefits, and maintains there is no law compelling a Medicaid
claimant to appeal an insurance carrier's adverse determination
following an internal review. Accordingly, petitioner argues,
the Division's decision was arbitrary, capricious, and
unreasonable.
Our scope of review of a final administrative decision is
limited. In re Stallworth, 208 N.J. 182, 194 (2011). "An
agency's determination on the merits 'will be sustained unless
there is a clear showing that it is arbitrary, capricious, or
unreasonable, or that it lacks fair support in the record.'"
Saccone v. Bd. of Trs. of Police & Firemen's Ret. Sys., 219 N.J.
369, 380 (2014) (quoting Russo v. Bd. of Trs., Police &
Firemen's Ret. Sys., 206 N.J. 14, 27 (2011)).
On the other hand, a court is not bound by an agency's
determination of a purely legal issue. Pinelands Pres. All. v.
State, Dept. of Envtl. Prot., 436 N.J. Super. 510, 524-25 (App.
Div. 2014). "Because an agency's determination on summary
decision is a legal determination, [such] review is de novo."
L.A. v. Bd. of Educ. of City of Trenton, Mercer Cty., 221 N.J.
192, 204 (2015) (citing Contini v. Bd. of Educ. of Newark, 286
N.J. Super. 106, 121-22 (App. Div. 1995)).
6 A-4669-14T4
"Medicaid is a medical assistance program for eligible low-
income individuals, established by Subchapter XIX of the federal
Social Security Act." Waldman v. Candia, 317 N.J. Super. 464,
470 (App. Div. 1999). This "program is administered jointly by
the federal and state governments." Ibid. States are not
required to participate in the program but, once a State joins,
the State's program must comply with the federal criteria. Id.
at 470-71.
The Department of Human Services, through the Division, is
designated as the state agency to administer New Jersey's
Medicaid program. N.J.S.A. 30:4D-5; N.J.S.A. 30:4D-7k. The
statutory provisions implementing Medicaid are set forth in the
Medical Assistance and Health Services Act, N.J.S.A. 30:4D-1 to
-42. Pursuant to that statute, the Division is vested with the
authority to administer Medicaid. N.J.S.A. 30:4D-7; see also 42
U.S.C.A. § 1396a(a)(5) (requiring States participating in
Medicaid to establish or designate a single state agency to
administer or supervise the plan).
"Congress, in crafting the Medicaid legislation, intended
that Medicaid be a 'payer of last resort.'" Ark. Dept. of Health
& Human Servs. v. Ahlborn, 547 U.S. 268, 291, 126 S. Ct. 1752,
1767, 164 L. Ed. 2d 459 (2006). "This means that all other
available resources must be used before Medicaid pays for the
7 A-4669-14T4
medical care of an individual enrolled in a Medicaid program."
Caremark, Inc. v. Goetz, 480 F.3d 779, 783 (6th Cir. 2007).
Because Medicaid is a "payer of last resort," federal law
requires "states to implement 'third party liability (TPL)
programs' which 'ensure that Federal and State funds are not
misspent for covered services to eligible Medicaid recipients
when third parties exist that are legally liable to pay for
those services.'" Wesley Health Care Ctr., Inc., v. DeBuono,
244 F.3d 280, 281 (2d Cir. 2001). A third party is "any
individual, entity or program that is or may be liable to pay
all or part of the expenditures for medical assistance furnished
under a State [Medicaid] plan." 42 C.F.R. § 433.136(3).
Federal Medicaid statute 42 U.S.C. 1396a(a)(25)(A) requires
each State's Medicaid agency take specific measures to find out
when third parties, such as private insurers, are legally
obliged to pay for services covered by Medicaid. Wesley, supra,
244 F.3d at 281 (citing 42 U.S.C. § 1396a(a)(25)(A)). New
Jersey's counterpart to the latter statute is N.J.S.A. 30:4D-
7(k), which authorizes the Division to take reasonable measures
to ascertain a third party's liability to a Medicaid claimant.
Waldman, supra, 317 N.J. Super. 464, 473 (App. Div. 1999).
Here, the Division takes the position that, before the
Division is required to pay benefits, it is reasonable to compel
8 A-4669-14T4
claimants to pursue any available administrative appeal of the
insurance carriers' adverse determinations. Because federal and
State law requires the Division to implement reasonable measures
to ascertain any third party's liability for a claimant's
medical bills, in general, we cannot fault the Division for
compelling potential claimants to seek DOBI's review of an
insurance company decision to deny coverage, unless it is clear
such review would be futile. Medicaid benefits are payments of
last resort, and the Division is tasked with ensuring such
payments are not expended if a third party is liable for a
claimant's medical expenses.
However, what is of concern to the court is whether
petitioner was on notice it had to seek DOBI's review or
otherwise pursue an administrative appeal of the insurance
companies' determinations before filing a claim for Medicaid
benefits. The Division did not provide, and we were unable to
find, a citation to any regulation or other authority that
alerted potential claimants of the necessity of seeking an
external review of an adverse determination by an insurance
company or like entity.
Compounding the matter is that, here, while these two
patients' claims were pending before it, the Division never
suggested to petitioner the claims were deficient or might be
9 A-4669-14T4
rejected because of petitioner's failure to seek review of the
insurance companies' determinations. Petitioner is now time-
barred from seeking DOBI review. The failure to provide notice
of the Division's decision to implement the measure of
compelling claimants to exhaust administratively available
appeals was raised by petitioner when before the ALJ, but was
not addressed by either the ALJ or the Director in their
respective decisions.
Accordingly, we remand this matter to the Division to
address the issue of notice and, depending on the outcome,
devise the appropriate remedy.
Remanded for further proceedings consistent with this
opinion. We do not retain jurisdiction.
10 A-4669-14T4
CARRIER CLINIC-PATIENTS A.M. AND C.I. VS. DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES(DEPARTMENT OF HUMAN SERVICES, DIVISION OF MEDICALASSISTANCE AND HEALTH SERVICES)
Combined Opinion