Section 69-10.16 - Claim and Prior Authorization Denial Review Process

69-10.16 Claim and Prior Authorization Denial Review Process.

(a) A request for review of a denial of a claim or of a prior approval request shall be made by completing and submitting a review request form provided by the Fund Administrator for denial of a claim or a prior approval request no later than thirty days from receipt of the denial. The form shall be provided to all enrollees and/or their parents(s), guardian(s) or legal representative(s) and shall be available on the Fund Administrator's website; and when completed, shall be submitted electronically, mailed or faxed to the Fund Administrator's office.

(b) A request for review of a denial of a claim or a prior approval request shall specify the denial that the enrollee is seeking to appeal and include the reason(s) the enrollee believes that the decision was incorrect and whether the requestor wants (1) a review based on documents submitted by both parties, (2) a review in the form of a hearing conducted by telephone, or (3) a review in the form of a hearing conducted in person. The review option chosen by the enrollee shall be the only form of review conducted by the Commissioner or his or her designee. A hearing officer, assigned by the Commissioner or his or her designee, will conduct the review regardless of whether the review is to be a document review or a review in the form of a hearing.

(c) If an enrollee who has had a prior approval request denied requests an informal conference in addition to a formal review, the Fund Administrator will designate a person to participate in an informal conference with the enrollee and/or his authorized representative to discuss the reason(s) for the denial. Any such conference will be scheduled to occur no later than one week before the formal review is scheduled to be held.

(d) Document Based Reviews. If the person representing the enrollee wishes a review based on documents instead of a hearing or if the hearing officer believes that the review can be conducted on the basis of documentation submitted by both parties without a hearing and neither party objects, the hearing officer will confer with both parties and set up a schedule for the submission and exchange of the documents on which each party intends to rely.

(1) No hearing officer shall review a matter toward which he or she has a personal bias. Prior to the submission of any documentation for review, any party may request that hearing officer be removed for personal bias or for other good cause by filing a request for removal accompanied by a supporting affidavit stating the basis for the request.

(2) A hearing officer may disqualify himself or herself for bias on his or her own determination.

(3) Any request for removal of a hearing officer on the basis of personal bias or for other good cause shall be reviewed by the Department of Health's Chief Administrative Law Judge, and the review shall not proceed until the Chief Administrative Law Judge reaches a decision on the request. Such decision shall be made within ten business days from receipt of the request for removal. If the Chief Administrative Law Judge determines there is good cause for removal, the review will be assigned to a different hearing officer simultaneously with the Chief Administrative Law Judge's determination.

(4) After reviewing all of the parties' submissions, the hearing officer shall render a written recommendation to the Commissioner within thirty days of receiving all submissions that includes the issues(s) raised on review, the relevant facts, and the applicable law, regulations, and official policies, if any, upon which the recommendation is based;

(5) The Commissioner or his or her designee shall review the documentation submitted by both parties and the hearing officer's recommendation and issue a decision that contains findings of fact, conclusions of law and the reason(s) for the determination and, when appropriate, directs the Fund Administrator to take specific action. The decision shall be issued promptly but no later than thirty days from issuance of the hearing officer's recommendation.

(6) A copy of the written decision shall be mailed to the parties and to the Fund Administrator. The decision of the Commissioner shall be final, provided that the enrollee or the provider may seek judicial review by a court of competent jurisdiction.

(7) The parties may enter into a stipulation to resolve the matter in dispute at any time prior to issuance of the decision. In the event that such a resolution is reached, the hearing officer will issue a consent order that incorporates the parties' stipulation. Such a consent order shall have the same force and effect as an order issued by the Commissioner.

(e) Hearings. Upon receipt of a request for a hearing, a hearing officer will be assigned; and the Commissioner or his or her designee shall serve a notice of hearing upon the party who requested the hearing and the Fund. If the requestor is an attorney, the notice will also be sent to the enrollee or, when applicable, his or her parent or other person authorized to act on his or her behalf.

(1) The notice of hearing shall, at a minimum:

(i) specify the date, time and place of the hearing, which, if conducted in person, shall be at a location within a reasonable distance from the requestor;

(ii) briefly state the issues that will be the subject of the hearing;

(iii) explain the manner in which the hearing will be conducted;

(iv) advise the requestor, if not an attorney, of the right to be represented by counsel and to be accompanied by any person of his or her choice. An interpreter may also be present when necessary.

(2) All notices and papers connected with the hearing may be served by ordinary mail, and service will be deemed complete three days after mailing.

(3) The assigned hearing officer shall preside over the hearing and related proceedings. The hearing and related proceedings shall be conducted in an impartial manner in accordance with the following procedures:

(i) No hearing officer shall preside over a matter toward which he or she has a personal bias. Prior to the hearing, any party may request that hearing officer be removed for personal bias or for other good cause by filing a request for removal accompanied by a supporting affidavit stating the basis for the request.

(ii) A hearing officer may disqualify himself or herself for bias on his or her own motion.

(iii) During the hearing, any party may request that the hearing officer be removed for bias by making such a request either orally or in writing on the record and stating the grounds for requesting removal of the hearing officer. The burden of proof shall be on the party seeking disqualification.

(iv) The hearing officer shall rule on the request for disqualification. If the hearing officer denies the request, the hearing shall proceed; but the Commissioner or his designee will review the entire record of the proceeding before a decision is issued. A written determination regarding whether the hearing officer should be removed from the proceeding will be issued within fifteen business days of the close of the hearing and will be made part of the record.

(4) The hearing officer shall conduct the hearing in a fair and impartial manner and shall have the power to:

(i) rule upon requests by all parties to the hearing, including requests for adjournments;

(ii) administer oaths and affirmations, issue subpoenas requiring the attendance of witnesses and the production of books, records and other evidence pertinent to the hearing;

(iii) admit or exclude evidence;

(iv) limit repetitious examination or cross-examination and the amount of corroborative or duplicative testimony;

(v) hear arguments on facts and law;

(vi) order the parties to present opening statements summarizing why the party believes the Fund Administrator's position was or was not correct;

(vii) order the parties to appear at a pre-hearing conference in an effort to simplify the issues, expedite the hearing, and/or to ensure that the parties understand the procedure;

(viii) ensure that a written or electronic verbatim record of the proceedings is made and made available to the parties;

(ix) perform such other acts as are necessary for the maintenance of order and the efficient conduct of the hearing unless otherwise prohibited by law or regulation; and

(x) adjourn the hearing to another time upon the request of any party for good cause shown or, upon the hearing officer's own motion, when the hearing officer determines that it would be prejudicial to a party's due process rights to go forward with the hearing on the scheduled date.

(5) The proceedings used to conduct the hearing shall provide the parties with a fair and prompt resolution of any dispute in accordance with the following procedures:

(i) The parties to the hearing may be represented by legal counsel or other individuals with specialized training relevant to the hearing and may be accompanied by a person of his or her choice.

(ii) The hearing shall be closed to the public unless the enrollee, or the enrollee's parent or other person authorized to act on his or her behalf if the enrollee is a minor, requests an open hearing.

(iii) The parties to the hearing and their respective counsel or representative shall have an opportunity to present evidence and to question all witnesses at the hearing.

(iv) Every witness shall be sworn or given an affirmation by the hearing officer.

(v) The hearing officer shall consider all relevant evidence and shall include all records, documents, and memoranda submitted into evidence. The formal rules of evidence shall not apply.

(vi) The parties may enter into a stipulation to resolve the matter in dispute at any time prior to issuance of the decision. In the event that such a resolution is reached, the hearing officer will issue a consent order that incorporates the parties' stipulation. Such a consent order shall have the same force and effect as an order issued by the Commissioner.

(6) Upon conclusion of the hearing, the hearing officer shall render a written recommendation to the Commissioner within thirty days of the hearing that includes the issues(s) raised at the hearing, the relevant facts, and the applicable law, regulations, and official policies, if any, upon which the recommendation is based;

(7) The Commissioner or his or her designee shall review the hearing record and the hearing officer's recommendation and issue a decision that contains findings of fact, conclusions of law and the reason(s) for the determination and, when appropriate, directs the Fund Administrator to take specific action. The decision shall be issued promptly but no later than thirty days from issuance of the hearing officer's recommendation.

(8) A copy of the written decision shall be mailed to the parties to the hearing and to the Fund Administrator. The decision of the Commissioner shall be final, provided that the enrollee or the provider may seek judicial review by a court of competent jurisdiction.

Effective Date: 
Wednesday, June 18, 2014
Doc Status: 
Complete