New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-W - Former Division of Human Services
Chapter He-W 500 - MEDICAL ASSISTANCE
Part He-W 506 - MEDICAID CARE MANAGEMENT (MCM)
Section He-W 506.09 - Department Fair Hearing Process
Current through Register No. 40, October 3, 2024
(a) A member shall exhaust the MCO or DO appeal process prior to filing a request for a fair hearing with the department, subject to the following:
(b) If the member does not agree with the MCO's or DO's resolution of an appeal, the member may file a request, in accordance with He-C 200, for a department fair hearing.
(c) Requests for a department fair hearing shall be made in writing within 120 calendar days of the date of the MCO's or DO's notice of the resolution of the appeal.
(d) A member in (b) above may request an expedited resolution of a department fair hearing if the department determines that the time otherwise permitted for a hearing could seriously jeopardize the member's life, physical or mental health, or ability to attain, maintain, or regain maximum function, and:
(e) The department shall notify the member as expeditiously as possible as to whether the request for an expedited department fair hearing is granted or denied. If oral notice is provided, the department shall follow up with written notice, which might be made through electronic means.
(f) If the department denies the member's request for an expedited department fair hearing, the department shall schedule a department fair hearing within 90 days from the date the member filed an MCO or DO appeal not including the number of days the member took to subsequently file for a department fair hearing.
(g) If the department grants the member's request for an expedited department fair hearing, then the department shall resolve the appeal within 3 business days after the department receives from the MCO or DO the case file and any other necessary information. The MCO or DO shall have no more than 3 days from the date the department notifies the MCO or DO that it has granted the member's expedited appeal, to provide the case file to the department.
(h) A member's benefits shall be continued during a department fair hearing if:
(i) If the member did not receive benefits pending the MCO or DO appeal, then a member's benefits shall be continued during a department fair hearing if:
(j) Only the member, the member's authorized representative, or the member's legal guardian may request benefits pending a department fair hearing of a MCO or DO decision.
(k) Providers acting as an authorized representative shall not request continuation of benefits pending the appeal even with written consent.
(l) If the MCO's or DO's adverse decision is upheld in a department fair hearing, the MCO or DO may institute recovery procedures against the member to recoup the cost of any continued benefits furnished to the member.
#10410, eff 9-13-13