Okla. Admin. Code § 317:2-3-12

Current through Vol. 42, No. 3, October 15, 2024

Section 317:2-3-12 - State fair hearing for members

(a)Right to state fair hearing. With regard to grievances or appeals first filed with the CE and DBM, a member may request a State fair hearing under 42 C.F.R. 431 Subpart E only after receiving notice from the CE and DBM upholding an adverse benefit determination. The member will have one-hundred twenty (120) days from the date of the adverse benefit determination notice to request a State fair hearing. Refer to 42 C.F.R. §§ 438.402(c)(1)(i) and 438.408(f)(1).

(b)CE or DBM policies and procedures. The CE and DBM will implement established policies and procedures that allow a member described in (a) to initiate a State fair hearing process after having exhausted the CE or DBM's appeals process or after the member is deemed to have exhausted the process due to the CE or DBM's failure to adhere to notice and timing requirements.

(c)Member's request for a state fair hearing. The CE and DBM will allow the member to request a State fair hearing either through an established CE and DBM process or through an established OHCA process. Any CE and DBM process will ensure that notice of the request for state fair hearing is communicated in writing to the OHCA contracting officer within twenty-four (24) clock-hours of receiving the request.

(d)CE or DBM documentation obligation. The CE and DBM will provide documentation to the member, the member's authorized representative, OHCA, and the Office of Administrative Hearings.

(1)Timing. The CE and DBM will provide the support documentation (summary) described in this subsection within fifteen (15) calendar days after notification of the request for state fair hearing.

(2)Information. support documentation (summary) will include, at minimum, the following information:

(A) The name and address of the member and, if applicable, the member's authorized representative;

(B) A summary statement concerning why the member has filed a request for State fair hearing;

(C) A brief chronological summary of the CE or DBM's action in relationship to the matter underlying the member's request for State fair hearing;

(D) The member's appeal request, along with any supporting documentation, if received by the CE and DBM;

(E) Any applicable correspondence between the CE and DBM and the member, including system notes entered by one (1) or more CE and DBM employees based on one (1) or more telephone conversations with the member;

(F) All exhibits offered at any hearing held with the CE and DBM;

(G) All documents the CE and DBM used to reach its decision;

(H) A statement of the legal basis for the CE or DBM's decision;

(I) A citation of the applicable policies and/or legal authorities relied upon by the CE or DBM in making its decision;

(J) A copy of the notice which notified the member of the decision in question;

(K) The names and titles of any CE or DBM employees who will serve as witnesses at the State fair hearing; and

(L) Any other information requested by the member, the member's authorized representative, OHCA, or the Office of Administrative Hearings when the information relates to the State fair hearing or any matter giving rise to the state fair hearing.

(e)CE or DBM staffing. The CE or DBM will maintain a sufficient level of staffing to competently perform the functions, requirements, roles, and duties involved in State fair hearing support, including but not limited to documentation, summarization of the arguments presented, and ensuring timely notice and delivery of documents to all parties.

(f)Performance targets. OHCA may set performance targets related to State fair hearing requests that are resolved upholding the CE or DBM's original determination when and as OHCA deems necessary or appropriate.

(g)Post-transition obligations. After termination or expiration of the Contract, the CE or DBM will remain responsible for State fair hearings related to dates of service prior to the Contract termination or expiration, including but not limited to the provision of records and representation at state fair hearings.

(h)Cost of services. If the state fair hearing officer reverses the CE or DBM's decision to deny authorization of services and the member received the disputed services while the State fair hearing was pending, the CE or DBM will pay for those disputed services.

Okla. Admin. Code § 317:2-3-12

Adopted by Oklahoma Register, Volume 39, Issue 10, February 1, 2022, eff. 12/21/2021

Adopted by Oklahoma Register, Volume 39, Issue 24, September 1, 2022, eff. 9/12/2022

Amended by Oklahoma Register, Volume 40, Issue 16, May 1, 2023, eff. 7/1/2023

Amended by Oklahoma Register, Volume 41, Issue 23, August 15, 2024, eff. 9/1/2024