Current through Register 1531, September 27, 2024
(A)
Timely Notice. Before an intended appealable action,
the MassHealth agency must send a written timely notice to the member except as
provided in
130
CMR 610.027. A timely notice is a notice
mailed at least ten days before the action. Such notice must include a
statement of the right of appeal and the time limit for appealing.
(B)
Time Limitation on the Right
of Appeal. The date of request for a fair hearing is the date on
which BOH receives such a request in writing. BOH must receive the request for
a fair hearing within the following time limits:
(1) 60 days after an applicant or member
receives written notice from the MassHealth agency of the intended action. Such
notice must include a statement of the right of appeal and the time limit for
appealing. In the absence of evidence or testimony to the contrary, it will be
presumed that the notice was received on the fifth day after mailing;
(2) unless waived by the BOH Director or his
or her designee, 120 days from
(a) the date of
application when the MassHealth agency fails to act on an
application;
(b) the date of
request for service when the MassHealth agency fails to act on such
request;
(c) the date of MassHealth
agency action when the MassHealth agency fails to send written notice of the
action; or
(d) the date of the
alleged coercive or otherwise improper conduct, but up to one year from the
date of the conduct if the appellant files an affidavit with the BOH Director
stating the following, and can establish the same at a hearing (failure to
substantiate the allegation either before or at the hearing will be grounds for
dismissal):
1. he or she did not know of the
right to appeal, and reasonably believed that the problem was being resolved
administratively or he or she was justifiably unaware of the conduct in
question; and
2. the appeal was
made in good faith.
(3) 30 days after a resident receives written
notice of an intent to discharge or transfer pursuant to
130
CMR 610.029(A);
(4) 30 days after a nursing facility
initiates a transfer or discharge or fails to readmit and fails to give the
resident notice;
(5) 14 days after
a resident receives written notice of an emergency intent to discharge or
emergency transfer pursuant to
130
CMR 610.029(B);
(6) 14 days after a resident receives written
notice of a transfer or discharge that is the result of a nursing facility's
failure to readmit the resident following hospitalization or other medical
leave of absence;
(7) for appeals
of a decision reached by a managed care contractor:
(a) 120 days after the member's receipt of
the managed care contractor's final internal appeal decision where the managed
care contractor has reached a decision wholly or partially adverse to the
member, provided however, that if the managed care contractor did not resolve
the member's appeal within the time frames described by
130
CMR 508.010(A), 120 days
after the date on which the time frame for resolving that appeal has
expired;
(b) for timing of request
for continuation of benefits pending appeal, see
130
CMR 610.036.
(8) for appeals of PASRR determinations, 30
days after an individual receives written notice of his or her PASRR
determination. In the absence of evidence or testimony to the contrary, it will
be presumed that the notice was received on the fifth day after
mailing.
(C)
Computation of Time.
(1) Computation of any period referred to in
130 CMR 610.000 is on the basis of calendar days, except where expressly
provided otherwise. Time periods expire on the last day of such periods, unless
the day falls on a Saturday, Sunday, legal holiday, or other day on which BOH
is closed, in which event the last day of the time period is deemed to be the
next day on which BOH is open.
(2)
In the absence of evidence or testimony to the contrary, it will be presumed
that a notice was received by an appellant on the fifth day after the date of
the notice, regardless of whether the fifth day after the date of the notice
falls on a Saturday, Sunday, legal holiday, or other day on which the BOH is
closed. If an appellant dies on or prior to the date of presumed receipt, then
for the purposes of determining whether an appeal request is timely, the
appealable notice is still presumed to have been received no later than the
fifth day after the date of the notice.
(D)
Time Limits for Rendering a
Decision.
(1) BOH must render a
final decision within 45 days of the date of request for a hearing when the
issue under appeal is
(a) the denial or
rejection of an application for assistance;
(b) the failure to act on an application in a
timely manner;
(c) a nursing
facility-initiated discharge or transfer; or
(d) a PASRR determination.
(2) BOH must render a final
decision within 45 days of a request for a fair hearing about appealable
actions by managed care contractors, except where the internal appeal was
expedited pursuant to
130
CMR 610.015(G) and
(H).
(3) BOH must render a final decision within
90 days of the date of request for a hearing for all other appeals.
(4) The time limits set forth in
130
CMR 610.015(D)(1) and (3)
and 130 CMR 610.015(E) and
(F) may be extended for good cause as
follows.
(a) When delays are caused by the
appellant or his or her appeal representative, the time limits may be extended
by the total number of days of such delays, which may include the advance
notice period before any rescheduled hearing dates. Such delays include the
appellant's delay in the submission of evidence, briefs, or other statements,
rescheduling or continuances granted at the request of or for the benefit of
the appellant, and any other delays caused by the actions of the appellant or
his or her appeal representative.
(b) When delays occur due to acts of nature,
serious illness, or other issues beyond the control of BOH that make a hearing
officer unable to render a timely decision, good cause for the extension of the
time limits will be deemed to exist.
(c) The hearing officer will document in the
hearing record and notify the applicant of any delay that the hearing officer
determines is excluded from the time limits set forth under
130
CMR 610.015(D)(1) and (3)
and 130 CMR 610.015(E) and
(F).
(E)
Expedited Appeals for Denied
Acute Hospital Admissions. When the MassHealth agency denies prior
authorization for an elective hospital admission of a member, the member may
request an expedited hearing. When such request is made, BOH will schedule a
hearing as soon as possible, but no later than seven days from the date BOH
receives the request. The hearing officer must render a final decision as soon
as possible, but no later than seven days from the date of the hearing. These
time limits may be extended pursuant to
130
CMR 610.015(D). A request
for an expedited hearing under
130
CMR 610.015(E)
automatically waives the requirement for ten-day advance notice of the hearing
under
130
CMR 610.046(A). The
appellant will be contacted, orally when possible, at least 48 hours before the
hearing.
(F)
Expedited
Appeals for Discharges and Transfers from a Nursing Facility under
130
CMR 610.029(B) or (C)
. A resident may request an expedited appeal when a nursing
facility notifies a resident of a discharge or transfer under the time frames
of 130 CMR 610.029(B) or
(C). When such a request is made, BOH will
schedule a hearing as soon as possible, but no later than seven days from the
date BOH receives the request. The hearing officer must render a final decision
as soon as possible, but no later than seven days from the date of the hearing.
These time limits may be extended pursuant to
130
CMR 610.015(D). Appeal
requests made under
130
CMR 610.015(F)
automatically waive the requirement for ten-day advance notice of the scheduled
hearing date under
130
CMR 610.046(A).
(G)
Expedited Hearings on Adverse
Managed Care Contractor Internal Appeals Decisions.
(1) A member may request an expedited hearing
at BOH with respect to an appealable action after exhausting the managed care
contractor's expedited appeals process (if required) where the managed care
contractor reached a decision on the member's expedited internal appeal wholly
or partially adverse to the member within the time frame described by
130
CMR 508.010(A).
(2) The member must submit such a request
within the time frames described by
130
CMR
610.015(B)(7)(a).
(3) The hearing officer must take final
administrative action as expeditiously as the member's health condition
requires, but no later than three business days after BOH receives from the
managed care contractor the case file and information for any such
appeal.
(H)
Expedited Hearings on Untimely Managed Care Contractor Internal
Appeals Decisions.
(1) A member
may request an expedited hearing at BOH with respect to an appealable action if
the managed care contractor's internal appeals process did not resolve the
member's expedited internal appeal within the time frame described by
130
CMR 508.010(B).
(2) The member must submit such a request to
BOH within the time frames described by
130
CMR 610.015(B)(6)(d), (B)(7), or
(B)(8), whichever is applicable.
(3) The hearing officer must take final
administrative action as expeditiously as the member's health condition
requires, but no later than three business days after BOH receives from the
managed care contractor the case file and information for any such
appeal.
