Md. Code Regs. 10.01.04.06

Current through Register Vol. 51, No. 9, May 3, 2024

Section 10.01.04.06 - Hearing Procedures

A. The appellant, the Program, the MCO, and the delegate agency shall have the opportunity to:

(1) Present witnesses;

(2) Present documentary evidence;

(3) Present oral and written argument without undue interference;

(4) Establish all facts and circumstances the administrative law judge judges to be pertinent; and

(5) Question or refute any testimony or evidence, including an opportunity to confront and cross-examine all witnesses the administrative law judge judges to be adverse.

B. All parties that wish to call a witness at the hearing shall subpoena the witness in accordance with Office of Administrative Hearings procedures in COMAR 28.02.01.11.T he appellant or authorized representative may subpoena any employees of the Department, MCO, or delegate agency whose action is being contested by the appellant or whose testimony may be relevant to the issues under consideration as determined by the administrative law judge.

C. Right to Review Record.

(1) If the Program, MCO, or delegate agency introduces as evidence documents from the case record, special investigation file, or other sources, the appellant shall have the opportunity to examine the:

(a) Persons who prepared the documents; and

(b) Case record or special investigation file for the purpose of discovering information favorable to the appellant's case.

(2) Except as specified in Regulation .05A of this chapter, in addition to the rights specified in §C(1) of this regulation and for purposes of defining reasonable notice under Regulation .03B(9) of this chapter, the appellant or the appellant's authorized representative shall have the opportunity to examine the appellant's case record or investigation file upon reasonable notice to the Program, the MCO, or the delegate agency as specified in COMAR 07.01.02.04.

(3) The Program shall have access to relevant portions of the appellant's medical record in accordance with Health-General Article, §4-305, Annotated Code of Maryland.

D. When a hearing involves a medical issue, such as a diagnosis, an examining physician's report or a medical review team's decision, an additional medical assessment of the appellant's condition shall be obtained and made part of the record if the administrative law judge considers it necessary. Any additional medical assessment shall be made by a person other than the person who made the original medical assessment and shall be obtained at the Department's expense.

E. The delegate agency shall be a party to the fair hearing if the fair hearing involves an issue of eligibility.

F. Appeal for an Individual Enrolled in an MCO.

(1) The parties to the appeal for an individual enrolled in an MCO include the MCO, the enrollee, and the enrollee's representative or the personal representative of a deceased enrollee's estate.

(2) If the appeal concerns the medical necessity of a denied, reduced, suspended, or terminated benefit or service to an MCO enrollee, and if the fair hearing meets the Department-established criteria for an expedited hearing as provided in Regulation .04A(3)(b)(ii) of this chapter, the Office of Administrative Hearings shall:

(a) Schedule the hearing and render a bench decision within 3 working days after the Office of Administrative Hearings receives the fair hearing request; and

(b) Issue a follow-up written decision within 30 days of rendering the bench decision if the Office of Administrative Hearings, the appellant or the appellant's authorized representative, and the MCO agree that a written decision is necessary.

(3) All other appeals from MCO decisions shall be:

(a) Scheduled for a hearing within 30 days of receipt of the appeal and decided on within 30 days of the hearing; and

(b) Otherwise governed by COMAR 10.09.71.05.

Md. Code Regs. 10.01.04.06

Regulations .06B and D amended effective January 14, 1985 (12:1 Md. R. 16); amended effective 46:23 Md. R. 1065, eff. 11/18/2019