Current through Register Vol. 35, No. 18, September 24, 2024
A.
Notice of hearing: Not less than 30 calendar days before the
provider administrative hearing, written notice is given to all parties
involved of the time, date, and place of the hearing. If an accommodation is
necessary, the party must notify the assigned ALJ at least 10 calendar days
prior to the hearing. The FHB includes in its written notice to the provider an
explanation of the HSD provider administrative hearing process and procedures,
and informs the provider HSD does not pay fees or costs incurred by the
provider as a result of the provider administrative hearing or district court
appeals of the final HSD provider administrative hearing decision.
B.
Postponement: A provider may
request, and is entitled to receive, one postponement of the scheduled provider
administrative hearing, as long as it does not interfere with the 120 calendar
day timeframe. Requests for more than one postponement are considered on a
case-by-case basis at the ALJ's discretion.
C.
Expedited hearing: The
parties may request an expedited hearing in cases involving a medical
assistance program (MAP) eligible recipient's health, safety, or service
availability concerns. The request must be made in writing and state in detail
the reasons why an expedited hearing is necessary. Granting an expedited
hearing is at the discretion of the ALJ.
D.
Group hearing: The ALJ may
respond to a series of individual requests for hearings by conducting a single
group hearing. In all group hearings, the HSD administrative hearing process
governing an individual hearing is followed. Each provider, his or her
authorized representative or legal counsel may present his or her case
individually. If a group hearing is arranged, each affected provider has the
right to withdraw from the group hearing in favor of an individual HSD provider
administrative hearing.
E.
Informal resolution conference: The parties are encouraged to hold an
informal resolution conference before the provider administrative hearing to
discuss the issues involved in the hearing. The informal resolution conference
is optional and does not delay or replace the provider administrative hearing
process. Conference participants may include the provider, his or her
authorized representative or legal counsel, MAD or other responsible agency
representatives, and the MAD selected claims and provider enrollment processing
contractor. The purpose of the informal resolution conference is to informally
review MAD's action and to determine whether the issues can be resolved by
mutual agreement. The issues to be decided at the provider administrative
hearing may also be clarified or further defined. Regardless of the outcome of
the informal resolution conference, a provider administrative hearing is still
held, unless the provider submits a written withdrawal of the request of the
provider administrative hearing.
F.
Pre-hearing conference: The
assigned ALJ schedules a pre-hearing conference within 30 calendar days of the
receipt of the provider's request for a HSD provider administrative hearing. A
pre-hearing conference is an informal proceeding and may occur telephonically.
(1)
Purpose of conference: The
purposes of the pre-hearing conference include, but are not limited to:
(a) expediting the disposition of the
action;
(b) identification,
clarification, formulation and simplification of issues;
(c) resolution of some or all
issues;
(d) exchange of documents
and information;
(e) preparing
stipulations of fact to avoid unnecessary introduction of evidence at the
hearing;
(f) review of audit
findings;
(g) reconsideration of a
suspension or withholding of payments;
(h) identifying the number of witnesses;
and
(i) facilitating the settlement
of the case.
(2)
Scheduling: A scheduling order shall be entered into, which shall
set the due date for the summary of evidence (SOE), due date for exhibits, and
sets the date for the provider administrative hearing. The order shall be
issued as soon as practicable, but in any event within 30 calendar days of the
request for provider administrative hearing.
(3)
Continuations and
rescheduling: A pre-hearing conference may be continued or rescheduled
with the consent of all parties after the 30 calendar day time limit.
(4)
Settlements, stipulations and
admissions: No offer of settlement made in a pre-hearing conference is
admissible as evidence at the later provider administrative hearing.
Stipulations and admissions are binding and may be used as evidence at the
provider administrative hearing. Any stipulation, settlement or consent order
reached between the parties is written and signed by the ALJ and all parties to
the provider administrative hearing.
(5)
Timeliness: The pre-hearing
conference will not delay or replace the provider administrative hearing
itself. Pre-hearing conferences may include the provider, his or her authorized
representative or legal counsel, MAD or other responsible agency
representatives, and the MAD selected claims and provider enrollment processing
contractor. Subsequent to the conference or in the event that any of the
parties to the provider administrative hearing fail to participate, the
scheduled hearing is still held, unless the provider submits a written request
for withdrawal.
(6)
Unresolved issues: If all matters in controversy are not resolved
at the pre-hearing conference, the ALJ sets a provider administrative hearing
date within 30 calendar days of the last conference date, or at a later time
agreed to by all parties, recognizing the 120 calendar day
timeframes.
(7)
Written
summaries: The ALJ may request the parties to submit a written summary
of all issues resolved at the pre-hearing conference.
(8)
Pre-hearing order: The may,
at his or her sole discretion, prepare or ask the parties to prepare a
pre-hearing order. The pre-hearing order may contain:
(a) statements of any contested facts and
issues;
(b) stipulation of matters
not in dispute;
(c) list of
witnesses to be called and the subject of their testimony;
(d) list of exhibits;
(e) discovery directives; or
(f) other matters relevant to the
issues.
(9)
Points
of law: The ALJ may direct the parties to submit memoranda on points of
law to inform the final decision, and may dictate the length and scope of the
submissions.
G.
Summary of evidence (SOE): A summary of evidence (SOE) is a document
submitted by MAD that provides preliminary information concerning the basis of
its or its selected claims and provider enrollment processing contractor's
action. The SOE may be amended by MAD at any point prior to the pre-hearing if
the ALJ and the provider, his or her authorized representative or legal counsel
receives copies of the amended SOE at least two working days of the pre-hearing
conference.
(1) The SOE must be provided at
least 10 working days prior to the pre-hearing conference or if the pre-hearing
conference is not held, within 10 working days prior to the scheduled provider
administrative hearing date.
(2)
The failure of MAD to timely provide the SOE may, at the ALJ's discretion,
result in its exclusion or a continuance of the hearing.
(3) MAD staff or its designee is responsible
for the preparation of the SOE and coordination of parties and witnesses. MAD
is responsible for the submission of the SOE to all parties.
(4) The summary of evidence shall contain:
(a) the provider's name, telephone number and
address and the status of any previous or concurrent appeal through the MAD or
its selected claims and provider enrollment processing contractor;
(b) the action, proposed action or inaction
being appealed;
(c) information on
which the action or proposed action is based with supporting documentation and
correspondence; and
(d) applicable
federal and state law, regulations, statutes, rules or any combination of
these.
H.
Availability of provider evidence:
(1) The provider, his or her authorized
representative or legal counsel will provide at least ten calendar days prior
to the hearing to the FHB assigned ALJ any document to be introduced as
evidence at the pre-hearing conference. The SOE may be amended by the provider,
his or her authorized representative or legal counsel at any point prior to the
pre-hearing if the ALJ and MAD receive copies of the amended SOE at least
within two working days of the pre-hearing conference. The FHB will forward to
the MAD administrative hearings unit copies of such evidence. MAD will then
make these available to its selected claims and provider enrollment processing
contractor.
(2) Failure of the
provider, his or her authorized representative or legal counsel to timely
provide the documentary evidence may result in its exclusion or a continuance
of the provider administrative hearing at the discretion of the ALJ.
I.
Availability of
information: MAD must:
(1) provide, on
request, in a timely manner and without charge, any documents in its possession
concerning the underlying action, that are not already in the provider's
possession, and that are necessary for a provider to decide whether to request
a hearing or to prepare for a provider administrative hearing; and
(2) allow the provider, his or her authorized
representative or legal counsel to examine all documents to be used at the
provider administrative hearing at a reasonable time before the date of the
provider administrative hearing and during such hearings; documents or records
which the provider would not otherwise have an opportunity to challenge or
contest, may not be introduced at the provider administrative hearing or be
taken into consideration by the ALJ.
