D.C. Mun. Regs. tit. 7, r. 7-157
Current through Register 71, No. 45, November 7, 2024
Rule 7-157 - OAH AND OHA, HEARING RULES157.1 OAH Rules 2950 through 2969 (OAH Rules) shall apply to management of PSWCP cases filed pursuant to Section 2324 of the Act (D.C. Official Code § 1-623.24 ) with the Department of Employment Services, Office of Hearings and Adjudications (OHA) and Office of Administrative Hearings (OAH).
157.2 If no procedure is specifically prescribed by the OAH Rules, the Superior Court for the District of Columbia Rules may be used as guidance, to the extent practicable.
157.3 The OAH Rules shall govern the conduct of hearing of cases filed pursuant to Section 2324 of the Act (D.C. Official Code § 1-623.24 ), unless the ALJ determines that their application impairs the ALJ's ability to ascertain the claimant's rights pursuant to Section 2324(b)(2) of the Act (D.C. Official Code § 1-623.24(b)(2) ).
157.4 Hearings before the Chief Risk Officer (CRO) requested pursuant to Section 2323 of the Act (D.C. Official Code § 1-623.23) shall be conducted under the following rules (the "ORM Hearing Rules"):
(a) Hearings before the CRO shall be held by a hearing representative appointed by the CRO.(b) A claimant, healthcare provider, or the Program may request an oral hearing or a hearing on the written record and shall so indicate on Form 9H:(1) Within thirty (30) calendar days after the date of the Program's decision denying authorization for medical care or services; or(2) Within six (6) months of the later of the date of the bill, the date of initial payment of the bill, or the date of the initial Explanation of Review.(c) The party requesting the hearing (hereinafter "hearing proponent") shall submit, with his or her request for a hearing, all evidence or written argument that he or she wants to present to the hearing representative.(d) If the Program is requesting the hearing pursuant to Section 2323 of the Act (D.C. Official Code § 1-623.23) , the Program shall mail a copy of the hearing request to all parties involved. Each other party shall have fifteen (15) days to file a written response with supporting evidence or written argument to the Program hearing request with the hearing representative.(e) If requested by any party, the hearing representative shall schedule an oral hearing and determine, at his or her discretion, whether the oral hearing will be conducted in person, by teleconference, by videoconference, or by other electronic means. The hearing representative shall have sole discretion to set the time, place, and method of the hearing. The hearing representative shall provide written notice through an acknowledgment letter to each party of the time, place, and method of the hearing. The acknowledgment letter shall be provided within a reasonable period of time prior to, but no less than seven (7) days before, the date and time of the hearing(f) After the oral hearing has been scheduled and the hearing representative has transmitted appropriate written notice to the parties, the hearing representative may, upon submission of proper written documentation of an unavoidable serious scheduling conflict (such as court-ordered appearance or trial, jury duty, or a previously scheduled medical procedure), grant a request from any party to reschedule the hearing, as long as the hearing can be rescheduled to a date and time that is no more than thirty (30) days after the originally scheduled date and time. When a request to postpone a scheduled hearing by the hearing proponent cannot be accommodated under this paragraph, no further opportunity for an oral hearing shall be provided. Instead, the hearing will take the form of a review of the written record.(g) Where either party or its representative is hospitalized for a non-elective reason or where the death of the claimant's, healthcare provider's, or representative's parent, spouse, child, or other immediate family member prevents attendance by the party or its representative at the hearing, the hearing representative shall, upon submission of proper documentation, grant a postponement beyond the period prescribed in paragraph (f) of this subsection.(h) A decision regarding rescheduling under paragraphs (d) through (g) of this subsection shall be in the sole discretion of the hearing representative.(i) When the proponent of an oral hearing fails to appear at the scheduled hearing, the hearing shall take the form of a review of the written record and a decision shall issue accordingly.(j) Before the date of the oral hearing, the hearing representative may change the format of the hearing from an oral hearing to a review of the written record upon the hearing proponent's request. The decision to grant or deny a change of format from an oral hearing to a review of the written record shall be in the sole discretion of the hearing representative.(k) A request for reasonable accommodation by an individual with a disability shall be made through the procedure described in the initial acknowledgement letter.(l) The hearing shall be an informal process, and the hearing representative shall not be bound by common law or statutory rules of evidence, by technical or formal rules of procedure, or by the Administrative Procedure Act.(m) During the hearing, the party requesting the hearing shall be given up to thirty (30) minutes to present argument in support of the relief sought; each responding party shall be given up to thirty (30) minutes to present argument in support of its position. The hearing representative may ask questions of those presenting information on behalf of any party.(n) When conducting the hearing, the hearing representative ma y review the claim file and any additional evidence submitted by the parties that has already been exchanged between the parties in advance of the hearing.(o) The hearing representative shall determine the conduct of the oral hearing. Oral hearings shall be limited to no more than ninety (90) minutes. The hearing representative may extend this limitation at his or her discretion or terminate the hearing at any time he or she determines that all relevant evidence has been obtained, or because of misbehavior on the part of the claimant and/or representative. The hearing representative may stay the hearing and direct the parties to address matters that come up during the hearing.(p) Argument at an oral hearing, including an oral hearing conducted by teleconference, videoconference, or other electronic means, shall be recorded and placed in the record. The transcript of the hearing shall be the official record of the hearing.(q) The Office of Risk Management shall file a transcript of the oral hearing with the Superior Court as a part of the agency record, upon request for a review of the hearing representative's decision made pursuant to Section 2323 of the Act (D.C. Official Code § 1-623.23 ).(r) The hearing record shall be closed after the hearing is held, unless the hearing representative, in his or her discretion, grants an extension. A request for an extension must be made orally at the hearing or submitted in writing no later than ten (10) days after the hearing is held. Only one (1) such extension may be granted. A copy of the hearing representative's decision on the extension request shall be transmitted to all parties.(s) When conducting a hearing on the written record, the hearing representative shall issue a decision within forty- five (45) days after receipt of the hearing request.(t) When conducting an oral hearing, the hearing representative shall issue a decision within thirty (30) days after the date of the oral hearing.(u) When conducting a hearing regarding the necessity, character, or sufficiency of medical care or service furnished, or scheduled to be furnished, the hearing representative may initiate a utilization review pursuant to Section 2323 of the Act (D.C. Official Code § 1-623.23) , and the relevant time periods set forth in paragraphs (s) and (t) of this section shall be stayed pending completion of the utilization review. The hearing representative shall issue a notice to all parties informing the parties that a utilization review has been initiated and that the time period for a decision has been stayed pending completion of utilization review.(v) The proponent of the hearing may withdraw the hearing request at any time up to the time the decision is issued.D.C. Mun. Regs. tit. 7, r. 7-157
Final Rulemaking published at 64 DCR 6325 (7/7/2017); amended by Final Rulemaking published at 66 DCR 4246 (4/5/2019)