10 Guam Code Ann. § 2915
Attorney's Note
Under the Guam Code, punishments for crimes depend on the classification. In the case of this section:| Class | Prison | Fine |
|---|---|---|
| misdemeanor | up to 1 year | up to $1,000 |
Terms Used In 10 Guam Code Ann. § 2915
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Complaint: A written statement by the plaintiff stating the wrongs allegedly committed by the defendant.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Fiscal year: The fiscal year is the accounting period for the government. For the federal government, this begins on October 1 and ends on September 30. The fiscal year is designated by the calendar year in which it ends; for example, fiscal year 2006 begins on October 1, 2005 and ends on September 30, 2006.
- Public defender: Represent defendants who can't afford an attorney in criminal matters.
(1) the client has a right to have another person of that client’s own choosing to assist with that client’s case; and
(2) if the client chooses to go through a hearing, an opportunity will be granted for a hearing conducted by an impartial hearing officer.
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(3) Notification of Time and Place of Hearing. The time, date and place of the hearing shall be arranged to provide the claimant and all other parties involved at least ten (10) working days of advance written notice. Notice shall:
(A) inform claimant of the time, date and place of the hearing;
(B) advise the claimant or representative of the name, address and phone number of the person to notify in the event it is not possible for the claimant to attend the scheduled hearing;
(C) specify that the agency will dismiss the hearing request if the claimant or the claimant’s representative fails to appear for the hearing without good cause;
(D) explain that the claimant or the claimant’s representative may examine the case file prior to the hearing; and
(E) advise the claimant of the possible availability of legal services from the Public Defender Service Corporation.
(4) Hearing Officer. hearing shall be conducted by an attorney or an arbitrator who does not have any personal stake or involvement in the case; and was not directly involved in the initial determination of the action which is being contested. Responsibilities of the hearing officer shall include:
(A) administer required oaths or affirmations; (B) insure all relevant issues are considered;
(C) request, receive and make part of record all evidence determined necessary to decide the
issues being raised; and
(D) regulate the conduct and course of the hearing, consistent with due process to insure an orderly hearing.
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(5) Hearing Decisions. The claimant shall be notified in writing of the decision and the reasons for the decision.
(6) After a hearing decision, which upholds the agency action, the claimant shall be notified of the right to pursue judicial review of the decision.
(b) A grievance or appeal shall be filed in writing and received by the Administrator no later than sixty (60) days after the date of the adverse action, decision or policy implementation being grieved. If a grievance or appeal is not filed within the time required by this Section, the initial decision shall be considered the final decision.
(c) (1) The Hearing Officer shall render a decision on each grievance no later than ninety (90) days from the date the Administrator receives the request for a hearing, unless the hearing is postponed or rescheduled at the request of all of the parties, or the hearing officer orders a further extension.
(2) If a person is dissatisfied with a final decision on a grievance properly submitted and heard under the provisions of this Article, the person may file for judicial review under the provisions of the Administrative Adjudication Law.
(d) Notice of Change in Benefits. Notice of a denial or discontinuance shall be made in writing to the client ten (10) days in advance, and state the reason and effective date.
SOURCE: Added by P.L. 25-163:1 (Sept. 21, 2000), repealed/reenacted by P.L. 27-030:2 (Sept. 30, 2003).
2017 NOTE: Subitem designations added/altered pursuant to the authority of 1 Guam Code Ann. § 1606.
§ 2916. Medically Indigent Program Reimbursement Fee
Schedules for Providers.
(a) Reimbursements to Providers and Non-Providers shall be in amounts not to exceed the following:
(1) for in-patient hospital services, the Program shall reimburse ervices in accordance with the annual Medicare per diem rates set for the hospital’s in-patient services;
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(2) for out-patient hospital services, the Program shall reimburse a hospital by applying the annual Medicare hospital specific out-patient cost-to-charge ratio to the covered charges;
(3) for skilled nursing services, the Program shall reimburse at fifty percent (50%) of the annual Medicare per diem rates set for the hospital’s in-patient services;
(4) for intermediate care services, the Program shall reimburse services at sixty percent (60%) of reimbursement rate established in § 2916(a)(3) for skilled nursing;
(5) for professional fees and home health services, the Program shall reimburse services at one hundred percent (100%) of the Medicare Participating Provider fee schedule rate adjusted in accordance with the Hawaii or Guam conversion factor as applicable; and
(6) for dental fees, the National Dental Advisory
Schedule shall be used to reimburse services.
(b) The Administrator of the Medically Indigent Program shall have discretionary authority to establish Provider and Non- Provider reimbursement rates for services which are not specifically addressed herein, but which are consistent with the Program services provided by § 2901 through § 2915 of this Article. Said schedules will be developed in conjunction with the Administrator’s duties to secure the necessary Provider and Non- Provider relationships to ensure the availability of adequate medical care and assistance to all Program recipients.
(1) The Program shall not pay claims for Program- covered services that are initially submitted more than twelve (12) months after the date of the service as clean claims, except for claims submitted for services to members involving the coordination of benefits amongst multiple payers.
(2) Payments shall be made on clean claims in accordance with the reimbursement rates set forth in this Section.
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(c) Clean claims as defined by this Article and as further defined herein shall mean:
(1) For a Hospital Bill. A hospital bill is considered received for purposes of this Subsection upon initial receipt of the legible claim form by the administration if the claim includes the following error-free documentation in legible form:
(A) an admission face sheet; (B) an itemized statement;
(C) an admission history and physical;
(D) a discharge summary or an interim summary if the claim is split;
(E) an emergency record, if admission was through the Emergency Room;
(F) operative reports, if applicable;
(G) a labor and delivery room report, if applicable; (H) utilization review report.
(2) For Medical Service Claims. For medical service claims, a claim that is submitted on a HCFA 1500 reflecting CPT and HCPCS codes for services and supplies. Services requiring prior authorization shall have a copy of the approved authorization form attached. Specialist services shall have the appropriate referral form attached.
(3) For Dental Claims. For dental claims, a claim that is submitted on the ADA claim form reflecting proper codes for services.
(4) For Behavioral Health Forms. For behavioral health forms, a claim submitted on a HCFA 1500 reflecting CPT codes for behavioral health services.
(d) Payment received by a Provider or Non-Provider from the Program is considered payment by the Program of the Program’s liability for the member’s bill. A Provider may collect any unpaid portion of its bill from other third party payers or the member in
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the event of non-covered services. A Provider or Non-provider shall not:
(1) charge, submit a claim to, demand or otherwise collect payment from a member or person who has been determined eligible, unless specifically authorized by this Article or rules adopted pursuant to this Article; or
(2) refer or report a member who has been determined eligible to a collection agency or credit reporting agency for the failure of the member to pay charges for Program covered care or services, unless specifically authorized by this Article or rules adopted pursuant to this Article.
(e) The Administrator may conduct post-payment review of all claims paid by the Program and may recoup any monies erroneously paid.
(1) The Administrator shall adopt rules that specify procedures for conducting post-payment review.
(2) The Program Administrator shall review all prepaid captivated payments and may conduct a post-payment review of all claims paid by the Program, and may recoup monies that are erroneously paid.
(A) Any Provider receiving reimbursements under this Article for which they were not entitled on the basis of false claims filed on behalf of any person receiving assistance under this Article shall be liable for repayment, and shall be guilty of a misdemeanor or felony, depending on the amount paid for which the person was not entitled, as specified in the Criminal and Correctional Code of Guam, Title 9 of the Guam Code Annotated.
(f) Claims for Program-covered services which are determined valid by the Administrator pursuant to § 2907 through
§ 2912.10, and the Program’s grievance and appeal procedure,
shall be paid from the funds established by this Section.
(g) For purposes of this Section, ‘Program-covered services’
exclude administrative charges for operating expenses.
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(h) All payments for services established by this Article shall be accounted for by the Administrator by the fiscal year in which the claims were paid, regardless of the fiscal year in which the payments were incurred.
(i) Notwithstanding any other law to the contrary, government-owned Providers are subject to all claims processing and payment requirements or limitations of this Article, which are applicable to non-government Providers.
(j) Notwithstanding any law to the contrary, the Director or Administrator may receive confidential adoption information for the purposes of identifying adoption-related third party payers in order to recover the total costs for prenatal care and the delivery of the child, including capitation reinsurance and any fee-for- service costs incurred by the Program on behalf of an eligible person who the Administrator has reason to believe had an arrangement to have the eligible person’s newborn adopted.
(1) Except for the sole purpose of identifying adoption- related third party payers, the Administrator shall not further disclose any information obtained pursuant to this Subsection, and shall develop and implement safeguards to protect the confidentiality of this information, including limiting access to the information to only those Program personnel whose official duties require it.
(2) At no time shall the Director or Administrator release to the adoptive parents’ or birth parents’ insurance carrier personally identifying information regarding the other party.
(3) A person who knowingly violates the requirements of this Subsection pertaining to confidentiality is guilty of a Class 6 felony.
SOURCE: Added by P.L. 25-163:1 (Sept. 21, 2000), repealed/reenacted by P.L. 27-030:2 (Sept. 30, 2003).
2017 NOTE: Sububitem designations added pursuant to the authority of 1
GCA § 1606.
2012 NOTE: In maintaining the general codification scheme of the GCA the Compiler changed the hierarchy of subsections beginning with “”Lowercase Roman Numerals”” to “”Uppercase Letters”” in subsection
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(c)(1).