Md. Code Regs. 10.67.10.02

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.67.10.02 - Appeal

A. From the decisions set forth in §B(1)-(8) of this regulation, an MCO may exercise the appeal rights set forth in §C of this regulation.

B. The following Department decisions are appealable by the MCO or MCO applicant:

(1) Denial of an entity's completed application to become an MCO;

(2) Decision to terminate the MCO's participation in the Maryland Medicaid Managed Care Program;

(3) Decision to impose a fine or other sanction on the MCO as described in Regulation .01 of this chapter;

(4) Order to provide benefits or services to enrollees as described in COMAR 10.67.71.05;

(5) Order that the MCO is impaired or in "hazardous financial condition";

(6) An adverse decision by the IRO as described in COMAR 10.67.86.08;

(7) The amount of a penalty or incentive as described in COMAR 10.67.65.03;

(8) The denial of a hepatitis C payment as described in COMAR 10.67.65.19;

(9) Overpayments recovered by the Department as described in COMAR 10.67.68.01; and

(10) Remittances to the Department as described in COMAR 10.67.65.19-5.

C. An MCO may appeal a decision listed in §B of this regulation to the Office of Administrative Hearings as specified in COMAR 10.01.03 and COMAR 10.67.36.09.

D. The parties to an appeal to the Office of Administrative Hearings under §C of this regulation are the Department and the MCO. The enrollee is not a party at this hearing.

E. The following sanctions shall take effect immediately and are not subject to stay during the pendency of an appeal:

(1) Any fines imposed;

(2) Orders to provide a benefit or service to enrollees;

(3) Any full or partial withhold of the capitation payment;

(4) Any remittances to the Department as described in COMAR 10.67.65.19-5; or

(5) Any overpayments recovered by the Department as described in COMAR 10.67.68.01.

Md. Code Regs. 10.67.10.02

Regulations .02 recodified from 10.09.73.02 effective 46:22 Md. R. 976, eff. 11/1/2019