Current through Register Vol. 51, No. 19, September 20, 2024
A. The
appellant, the Program, the MCO, and the delegate agency shall have the
opportunity to:
(1) Present
witnesses;
(2) Present documentary
evidence;
(3) Present oral and
written argument without undue interference;
(4) Establish all facts and circumstances the
administrative law judge judges to be pertinent; and
(5) Question or refute any testimony or
evidence, including an opportunity to confront and cross-examine all witnesses
the administrative law judge judges to be adverse.
B. All parties that wish to call a witness at
the hearing shall subpoena the witness in accordance with Office of
Administrative Hearings procedures in COMAR 28.02.01.11.T he appellant or
authorized representative may subpoena any employees of the Department, MCO, or
delegate agency whose action is being contested by the appellant or whose
testimony may be relevant to the issues under consideration as determined by
the administrative law judge.
C.
Right to Review Record.
(1) If the Program,
MCO, or delegate agency introduces as evidence documents from the case record,
special investigation file, or other sources, the appellant shall have the
opportunity to examine the:
(a) Persons who
prepared the documents; and
(b)
Case record or special investigation file for the purpose of discovering
information favorable to the appellant's case.
(2) Except as specified in Regulation .05A of
this chapter, in addition to the rights specified in §C(1) of this
regulation and for purposes of defining reasonable notice under Regulation
.03B(9) of this chapter, the appellant or the appellant's authorized
representative shall have the opportunity to examine the appellant's case
record or investigation file upon reasonable notice to the Program, the MCO, or
the delegate agency as specified in COMAR 07.01.02.04.
(3) The Program shall have access to relevant
portions of the appellant's medical record in accordance with Health-General
Article, §4-305, Annotated Code of Maryland.
D. When a hearing involves a medical issue,
such as a diagnosis, an examining physician's report or a medical review team's
decision, an additional medical assessment of the appellant's condition shall
be obtained and made part of the record if the administrative law judge
considers it necessary. Any additional medical assessment shall be made by a
person other than the person who made the original medical assessment and shall
be obtained at the Department's expense.
E. The delegate agency shall be a party to
the fair hearing if the fair hearing involves an issue of
eligibility.
F. Appeal for an
Individual Enrolled in an MCO.
(1) The parties
to the appeal for an individual enrolled in an MCO include the MCO, the
enrollee, and the enrollee's representative or the personal representative of a
deceased enrollee's estate.
(2) If
the appeal concerns the medical necessity of a denied, reduced, suspended, or
terminated benefit or service to an MCO enrollee, and if the fair hearing meets
the Department-established criteria for an expedited hearing as provided in
Regulation .04A(3)(b)(ii) of this chapter, the Office of Administrative
Hearings shall:
(a) Schedule the hearing and
render a bench decision within 3 working days after the Office of
Administrative Hearings receives the fair hearing request; and
(b) Issue a follow-up written decision within
30 days of rendering the bench decision if the Office of Administrative
Hearings, the appellant or the appellant's authorized representative, and the
MCO agree that a written decision is necessary.
(3) All other appeals from MCO decisions shall be:
(a) Scheduled for a hearing within 30 days of
receipt of the appeal and decided on within 30 days of the hearing;
and
(b) Otherwise governed by COMAR
10.09.71.05.
