A Pennsylvania appeals court rules that an appeal filed by a nursing home five years after the state denied Medicaid benefits to a resident is untimely and that there was no breakdown in the administrative process that would justify allowing the appeal to proceed. Congdon v. Department of Human Services (Pa. Commw. Ct., No. 1817 C.D. 2015, May 25, 2016).
Elizabeth Congdon entered a nursing home, and the nursing home applied for Medicaid benefits on her behalf. After receiving financial records from Ms. Congdon's daughter, the state denied her application in April 2010, finding that she had excess resources. The nursing home applied for benefits on Ms. Congdon's behalf again in May 2011, and the state granted benefits.
In February 2015, the nursing home filed an appeal of the 2010 denial of benefits, arguing that an appeal nunc pro tunc was warranted because the state did not determine whether Ms. Congdon was capable of responding to the denial. The hearing officer found that the appeal was untimely, and the nursing home appealed to court, arguing that the state was required to help Ms. Congdon with her appeal and that it should have retained the denial notices sent to Ms. Congdon and her daughter.
The Pennsylvania Commonwealth Court, an appellate court, affirms the state's denial of the appeal as untimely. According to the court, there was no breakdown in the administrative process that would justify allowing an appeal nunc pro tunc. The court notes that Ms. Congdon's daughter assisted her during the application process and that there was no evidence she had requested additional assistance. In addition, there was no evidence that Ms. Congdon's daughter was not aware of the denial and there was evidence that the nursing home was aware because it applied for benefits on Ms. Congdon's behalf again in May 2011.
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