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ODP Fair Hearing Request Form

ODP Announcement 109-18 announces that the Fair Hearing Request Form (DP 458) has been updated. The form is used by individuals and families to object to the following actions taken by the Administrative Entity (AE), County Program, Supports Coordination Organization (through the auto authorization process), or ODP and to request a fair hearing before the Department of Human Services, Bureau of Hearings and Appeals:

  • An individual is determined likely to meet an Intermediate Care Facility for persons with an Intellectual Disability (ICF/ID) or Other Related Conditions (ICF/ORC) level of care and is enrolled to receive Medical Assistance but is not given the opportunity to express a service delivery preference for either Waiver or ICF/ID services.
  • An individual is denied preference of Waiver, Targeted Support Management, or ICF/ID services.
  • Based on a referral from the AE or County Program, a Qualified Developmental Disability Professional (QDDP) determines that an individual does not require an ICF/ID or ICF/ORC level of care and eligibility for services denied or terminated.
  • An individual is denied Waiver service(s) of their choice, including the amount, duration, and scope of service(s).
  • An individual is denied the choice of willing and qualified Waiver or Targeted Support Management provider(s).
  • A decision or an action is taken to deny, suspend, reduce, or terminate a Waiver service authorized on the individual’s Individual Support Plan (ISP).

If an individual or family needs assistance completing the form, the AE, County Program, Supports Coordinator, or Targeted Support Manager may help.

The Fair Hearing Request Form should not be completed for actions taken by the County

Program regarding base-funded services. Base-funded services are services that are not paid for through a waiver and do not include Targeted Support Management. Denial of eligibility for base-funded services and individuals who have had base-funded services denied, reduced, or terminated have the right to appeal under the Local Agency Law.

The Fair Hearing Request Form should not be completed for actions taken regarding services in the Adult Autism Waiver or Adult Community Autism Program at this time. Individuals who would like information about how to request a fair hearing for an action regarding the Adult Autism Waiver or Adult Community Autism Program should talk to their Supports Coordinator. The updated Fair Hearing Request Form and accompanying instructions are here.

Questions about this communication should be directed to the appropriate Office of Developmental Programs Regional Office.