D.C. Mun. Regs. tit. 7, r. 7-156

Current through Register 71, No. 45, November 7, 2024

Rule 7-156 - OFFICE OF RISK MANAGEMENT, JURISDICTION

156.1

A claimant who is dissatisfied with a decision issued by the Program, other than a decision subject to review by OAH as set forth in § 155 of this chapter, may only appeal the decision to the Chief Risk Officer.

156.2

Appeals to the Chief Risk Officer shall:

(a) Be filed within fifteen (15) days from the date the decision was issued, unless otherwise provided or good cause is established when filed after fifteen (15) days to permit consideration of the appeal;

(b) Contain information required under this chapter; and

(c) Include all documents and other evidence in support of the claimant's arguments.

156.3

The Chief Risk Officer shall affirm the Program's decision if it is supported by substantial evidence in the record. Otherwise, at the discretion of the Chief Risk Officer, the claimant's appeal may be dismissed for failure to state a claim, lack of jurisdiction, procedural errors, or other appropriate reason or the Program's decision may be affirmed, modified, or remanded to the Program with instructions.

156.4

The Chief Risk Officer shall notify the claimant in writing of his or her decision within thirty (30) days after the Program's receipt of the appeal. If no decision is issued within the thirty (30)-day period, the Program's decision shall be deemed the final decision of the agency for appeal to the Superior Court of the District of Columbia as provided in § 156.5 of this chapter, unless the Chief Risk Officer issues a decision before the date on which the appeal to the Superior Court is filed.

156.5

The final decision of the agency under § 156.4 may be reviewed by the Superior Court of the District of Columbia on timely petition for review by the employee pursuant to District of Columbia Superior Court Rules of Civil Procedure Agency Review Rule 1.

156.6

A dispute arising under Section 2323 of the Act (D.C. Official Code § 1-623.23) between a qualified health professional, claimant, or the Program on the issue of necessity, character, or sufficiency of the medical care, supply, or service furnished, or scheduled to be furnished, or the fees charged by the healthcare provider (including a physician or organization providing Additional Medical Examination or utilization review services) shall be resolved by the Chief Risk Officer upon application for a hearing by the Program, claimant, or healthcare provider, in accordance with the applicable hearing rules provided at § 157 of this chapter.

156.7

As provided in Section 2323 (a-2)(4) of the Act (D.C. Official Code § 1-623.23 (a-2)(4)):

(a) The decision of the Chief Risk Officer pursuant to § 156.6 of this chapter may be reviewed by the Superior Court of the District of Columbia;

(b) The decision may be affirmed, modified, revised, or remanded in the discretion of the court; and

(c) The decision shall be affirmed by the court if supported by substantial competent evidence on the record.

D.C. Mun. Regs. tit. 7, r. 7-156

Final Rulemaking published at 64 DCR 6325 (7/7/2017); amended by Final Rulemaking published at 66 DCR 4246 (4/5/2019)