Section 360-6.5 - Fair hearing requirements in utilization review cases.

360-6.5 Fair hearing requirements in utilization review cases. When a utilization review committee determines that MA payments should be reduced or discontinued, the following steps must be taken:

(a) If the recipient is in a long-term care facility (a skilled nursing facility, intermediate care facility or mental hospital) or is a chronic care patient in a general hospital facility:

(1) The recipient, his/her representative, or an appropriate relative must be notified of the action in writing by the utilization review committee. The notice must be notified of the action in writing by the utilization review committee. The notice must be both timely and adequate as defined in Part 358 of this Title. The notice and action must be consistent with both State and Federal requirements on utilization review.

(2) If the recipient requests a fair hearing before the effective date of the action, payment for the recipient's care in a long-term care facility or for long-term care in a general hospital will be continued until the fair hearing decision is rendered.

(b) If the recipient is in a general hospital, but not receiving chronic care services:

(1) The recipient, his/her representative, or an appropriate relative must be notified of the action in writing by the utilization review committee. The notice must be adequate, as defined in Part 358 of this Title. The notice and action must be consistent with both State and Federal requirements on utilization review.

(2) MA payments on behalf of the recipient will be terminated on the effective date of the utilization review committee determination.

(3) MA payments will not be continued on behalf of the recipient if the recipient requests a fair hearing to contest a determination that hospitalization is no longer necessary.

(c) All provisions of Part 358 of this Title which are not inconsistent with subdivisions (a) and (b) of this section apply to utilization review committee determinations.

 

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