DHHS Appeals Unit Has Jurisdiction Over Licensed Medicaid Provider Challenges to MCO Recoupment Decisions

Introduction

In Petition of Metro Treatment of N.H., 2026 N.H. 20, the New Hampshire Supreme Court addressed whether the Administrative Appeals Unit of the New Hampshire Department of Health and Human Services has subject matter jurisdiction over a payment dispute between a Medicaid provider and a Medicaid Managed Care Organization.

The petitioner, Metro Treatment of New Hampshire, L.P., operates DHHS-licensed outpatient opioid treatment clinics. The respondent, AmeriHealth Caritas New Hampshire, is a Medicaid Managed Care Organization that contracts to arrange Medicaid services for enrolled recipients. After an audit, AmeriHealth sought to recoup alleged overpayments from Metro. Metro challenged the recoupment but argued that the AAU lacked jurisdiction because the dispute was between a provider and an MCO, not directly between Metro and DHHS.

The central legal issue was whether RSA 126-A:5, VIII authorizes the AAU to hear an appeal by a DHHS-licensed provider concerning an MCO’s attempted recoupment of Medicaid payments.

Summary of the Opinion

The Supreme Court affirmed the AAU’s determination that it had jurisdiction. The court held that RSA 126-A:5, VIII creates an appeals process that includes appeals by “providers, programs, services, or facilities which are licensed or certified by the department.” Because Metro was a DHHS-licensed provider, its appeal fell within that statutory category.

The court rejected Metro’s argument that DHHS administrative rules narrowed the AAU’s jurisdiction to only direct DHHS decisions or actions. Administrative rules cannot add to, detract from, or modify statutory law. Since the statute itself did not limit provider appeals to direct departmental actions, the rules could not impose that limitation.

The court therefore affirmed and remanded for further proceedings before the AAU. It expressly declined to decide whether the AAU’s jurisdiction is exclusive.

Analysis

Precedents Cited

Petition of Mason

The court relied on Petition of Mason, 177 N.H. 112 (2024), for the standard of review applicable to AAU decisions. Under that precedent, a petition for a writ of certiorari is the only mechanism for reviewing an AAU decision. Certiorari is extraordinary and discretionary, available only when necessary to avoid substantial injustice.

Petition of Mason also supplied the governing standard for reviewing statutory and regulatory interpretation: the court reviews such questions de novo, gives words their plain and ordinary meaning, interprets statutes and regulations as written, and construes the statutory scheme as a whole.

Appeal of Campaign for Ratepayers' Rights

The court cited Appeal of Campaign for Ratepayers' Rights, 162 N.H. 245 (2011), for two important administrative-law principles.

First, administrative agencies possess only limited and special subject matter jurisdiction. Their power depends entirely on the statutes that create and authorize them. An agency cannot create jurisdiction for itself.

Second, the court relied on the same case for the rule that agency regulations may not add to, subtract from, or modify statutory law. This principle was central to rejecting Metro’s argument that DHHS rules limited the AAU’s jurisdiction more narrowly than RSA 126-A:5, VIII.

Legal Reasoning

The court began with the text of RSA 126-A:5, VIII. That provision requires the DHHS commissioner to establish an appeals process for several categories, including:

  • individuals applying for or receiving services from DHHS or its contract service providers;
  • providers, programs, services, or facilities licensed or certified by DHHS;
  • actions related to DHHS employees; and
  • other matters within DHHS jurisdiction.

The court concluded that the statute creates a distinct right of appeal for DHHS-licensed or certified providers. Its reasoning relied on grammar and statutory structure. The repeated use of the word “any” before both “individual” and “providers, programs, services, or facilities” suggested two separate categories. The court also noted that subparagraphs of RSA 126-A:5, VIII refer separately to service applicants, facilities, licenses, and employees, confirming that the legislature contemplated multiple classes of appellants.

Because Metro operates DHHS-licensed opioid treatment clinics, it qualifies as a provider licensed by the department. That fact was enough to establish AAU jurisdiction under the second statutory category.

Metro argued that DHHS administrative rules limited appeals to departmental decisions or actions, not MCO decisions. The court rejected that argument. The statute did not impose such a limitation, and administrative rules cannot narrow statutory jurisdiction. The court also observed that AmeriHealth’s recoupment effort arose from Metro’s alleged noncompliance with DHHS opioid treatment regulations and directly concerned services provided to Medicaid recipients.

Impact

This decision is significant for Medicaid providers, MCOs, and DHHS-administered appeals in New Hampshire.

  • Provider appeal rights are strengthened. DHHS-licensed providers may seek AAU review of certain Medicaid payment disputes involving MCO recoupment decisions.
  • MCO recoupment decisions may be administratively reviewable. Even when an MCO, rather than DHHS directly, seeks recoupment, the AAU may have jurisdiction if the dispute concerns a licensed provider and Medicaid-funded services.
  • Administrative rules cannot narrow statutory jurisdiction. Agencies cannot rely on procedural rules to restrict appeal rights that the legislature has conferred.
  • The decision preserves DHHS oversight of Medicaid administration. Because Medicaid managed care involves public funds and DHHS-regulated services, disputes over alleged overpayments remain connected to DHHS’s regulatory responsibilities.

The court was careful to limit its holding. It did not decide whether AAU jurisdiction is exclusive, nor did it decide the merits of AmeriHealth’s recoupment claim against Metro.

Complex Concepts Simplified

  • Subject matter jurisdiction: The legal authority of a tribunal or agency to hear a particular type of dispute.
  • Managed Care Organization: A private or quasi-private entity that contracts to arrange healthcare services for Medicaid recipients, often under a fixed payment structure.
  • Recoupment: An effort to recover money previously paid, usually because the payer believes the payment was improper or excessive.
  • Writ of certiorari: An extraordinary form of judicial review used when there is no ordinary appeal route.
  • De novo review: A fresh review by the court, without deference to the lower tribunal’s interpretation of law.
  • Administrative rule versus statute: A rule adopted by an agency must fit within the statute authorizing it. A rule cannot override, narrow, or expand the statute.

Conclusion

Petition of Metro Treatment of N.H. establishes that the DHHS Administrative Appeals Unit has jurisdiction under RSA 126-A:5, VIII to hear an appeal by a DHHS-licensed provider challenging an MCO’s Medicaid overpayment recoupment decision. The decision emphasizes that statutory appeal rights cannot be narrowed by administrative rules and confirms the AAU’s role in resolving disputes connected to DHHS-licensed Medicaid services.

The ruling is an important clarification of New Hampshire Medicaid administrative law, particularly in the managed-care context.