Background
Metro Treatment of New Hampshire, L.P. (Metro) operates DHHS-licensed outpatient opioid treatment clinics whose patients include individuals enrolled in AmeriHealth Caritas New Hampshire (AmeriHealth), a Medicaid Managed Care Organization (MCO). Following an audit of patient records, AmeriHealth sought to recoup $36,722.27 in alleged overpayments, claiming Metro had violated New Hampshire Administrative Rules governing opioid treatment programs. After an internal appeal process reduced the recoupment amount by $556.13, AmeriHealth directed Metro to pursue further dispute resolution through a State Fair Hearing under RSA 126-A:5, VIII.
Metro filed an appeal with the Administrative Appeals Unit (AAU) of the New Hampshire Department of Health and Human Services (DHHS), while simultaneously contesting the AAU’s authority to hear the matter. The AAU issued a written decision asserting jurisdiction under RSA 126-A:5, VIII to hear appeals arising from determinations that Medicaid payments were inappropriately made and should be recouped. Metro moved for reconsideration, which was denied, and the AAU stayed proceedings pending Metro’s petition for certiorari to the New Hampshire Supreme Court.
The sole question before the Supreme Court was whether the AAU has subject matter jurisdiction over a payment dispute in which an MCO seeks to recoup alleged Medicaid overpayments from a contracted healthcare provider—where the recoupment determination was made by the MCO, not by DHHS directly.
The Court’s Holding
The New Hampshire Supreme Court affirmed the AAU’s assertion of jurisdiction and remanded for further proceedings. Writing for a unanimous court, Justice Donovan held that RSA 126-A:5, VIII establishes four categories of appeals, including a discrete category for “any providers, programs, services, or facilities which are licensed or certified by the department.” Because Metro’s clinics are DHHS-licensed providers of addiction treatment services, that statutory language squarely confers AAU jurisdiction over Metro’s appeal.
The court rejected Metro’s argument that the AAU’s own administrative rules narrow its jurisdiction to appeals from direct DHHS decisions or actions, and that MCO recoupment determinations therefore fall outside the AAU’s reach. The court reasoned that agency rules cannot modify or restrict the statutory grant of jurisdiction, and that the plain text of RSA 126-A:5, VIII imposes no such limitation. The court further concluded that the rule treating “references to the department” as including “contract service providers” applies beyond proceedings brought directly by individual Medicaid beneficiaries, encompassing appeals—like this one—that arise from services provided to those individuals.
The court expressly declined to address whether AAU jurisdiction is exclusive in this context, as that question was not before it, and found it unnecessary to resolve whether jurisdiction also exists under any of the other statutory categories given that the second category was sufficient.
Key Takeaways
- DHHS-licensed healthcare providers may invoke the AAU appeals process under RSA 126-A:5, VIII to challenge Medicaid overpayment recoupment demands initiated by MCOs, not only those initiated by DHHS itself.
- Agency administrative rules that purport to limit appeals to “department decisions or actions” cannot narrow the broader statutory grant of jurisdiction to licensed providers under RSA 126-A:5, VIII.
- MCO recoupment demands grounded in alleged violations of DHHS administrative rules—and arising from services rendered to Medicaid beneficiaries—are matters sufficiently connected to DHHS’s oversight authority to fall within the AAU’s jurisdiction.
- The court left open whether AAU jurisdiction over such disputes is exclusive, signaling that future litigation may address whether providers have parallel remedies elsewhere.
Why It Matters
This decision clarifies the administrative forum available to Medicaid providers in New Hampshire who face payment recoupment demands from MCOs. By holding that the AAU’s jurisdiction under RSA 126-A:5, VIII extends to licensed providers challenging MCO-initiated clawbacks—not just disputes where DHHS itself has acted—the court ensures that providers have a defined state administrative avenue to contest overpayment determinations without first securing DHHS’s direct involvement.
For opioid treatment programs and other DHHS-licensed facilities contracting with Medicaid MCOs, the ruling has immediate practical significance: disputes over payment recoupment tied to alleged regulatory violations can be adjudicated through the AAU rather than solely through private contract mechanisms. The court’s reservation on whether AAU jurisdiction is exclusive also leaves open an important question that may shape future litigation strategy for both providers and MCOs operating in New Hampshire’s Medicaid managed care system.