(1) A service provider may request an administrative review of a certification action within twenty-eight days of receipt of the written notice of the department's certification action.

(2) The service provider must make the request in writing and must:

(a) Sign the request;

(b) Identify the challenged decision and the date it was made;

(c) State specifically the issues and regulations involved and the grounds for the disagreement; and

(d) Include with the request copies of any supporting documentation for the service provider's position.