Current through Vol. 41, No. 13, March 15, 2024
(a)
Request
for appeals.
(1) For the purpose of
calculating the timeframe for requesting an administrative appeal of an Agency
action, the date on the written notice shall not be included. The last day of
the timeframe shall be included, unless it is a legal holiday as defined by
Title 25 of the Oklahoma Statutes (O.S.) Section (§) 82.1, or any other
day the Oklahoma Health Care Authority (OHCA) is closed or closes early, in
which case, the timeframe runs until the close of the next full business
day.
(2) An appeals request that an
aggrieved member or provider sends via mail is deemed filed on the date that
the Agency receives it.
(b)
Member process overview.
(1) The appeals process allows a member to
appeal a decision relating to program benefits. Examples are decisions
involving medical services, prior authorizations for medical services, or
discrimination complaints.
(2) In
order to initiate an appeal, the member must file a LD-1 (Member
Complaint/Grievance Form) within thirty (30) calendar days of the date the OHCA
sends written notice of its action, in accordance with Oklahoma Administrative
Code (OAC)
317:2-1-2(a),
above, or, in matters in which a formal notice is not sent by the Agency,
within thirty (30) days of the date on which the member knew or should have
known the facts or circumstances serving as the basis for appeal.
(3) If the LD-1 form is not received timely,
the OHCA administrative law judge (ALJ) will cause to be issued a letter
stating the appeal will not be heard. In the case of tax warrant intercept
appeals, if the LD-1 form is not received by OHCA within the timeframe pursuant
to 68 O.S. §
205.2, OHCA similarly will cause
to be issued a letter stating the appeal will not be heard because it is
untimely.
(4) If the LD-1 form is
not completely filled out or if necessary, documentation is not included, then
the appeal will not be heard.
(5)
OHCA will advise members that if assistance is needed in reading or completing
the grievance form, arrangements will be made to provide such
assistance.
(6) Upon receipt of the
member's appeal, a fair hearing before the OHCA ALJ will be scheduled. The
member will be notified in writing of the date and time of the hearing. The
member, and/or his/her designated authorized representative, must appear at the
hearing, either in person or telephonically. The preferred method for a hearing
is telephonically, requests for an in-person hearing must be received in
writing on OHCA's Form LD-4 (Request for In-Person Hearing) no later than ten
(10) calendar days prior to the scheduled hearing date.
(7) The hearing shall be conducted according
to OAC 317:2-1-5. The OHCA ALJ's
decision may in certain instances be appealed to the CEO of the OHCA, or his or
her designated independent ALJ, which is a record review at which the parties
do not appear (OAC
317:2-1-13).
(8) Member appeals are ordinarily decided
within ninety (90) days from the date on which the member's timely request for
a fair hearing is received, unless:
(A) The
appellant was granted an expedited appeal pursuant to OAC
317:2-1-2.5;
(B) The OHCA cannot reach a decision because
the appellant requests a delay or fails to take a required action, as reflected
in the record;
(C) There is an
administrative or other emergency beyond OHCA's control, as reflected in the
record; or
(D) The appellant filed
a request for an appeal of a denied step therapy exception request, pursuant to
OAC 317:2-1-18.
(9) Tax warrant intercept appeals will be
heard directly by the OHCA ALJ. A decision is normally rendered by the OHCA ALJ
within twenty (20) days of the hearing.
(c)
Provider process overview.
(1) The proceedings as described in this
subsection contain the hearing process for those appeals filed by providers.
These appeals encompass all subject matter cases contained in OAC
317:2-1-2(d)(2).
(2) All provider appeals are initially heard
by the OHCA ALJ under OAC
317:2-1-2(d)(2).
(A) In order to initiate an appeal, a
provider must file the appropriate LD form within thirty (30) calendar days of
the date the OHCA sends written notice of its action, in accordance with OAC
317:2-1-2(a),
above. LD-2 forms should be used for Program Integrity audit appeals; LD-3
forms are to be used for all other provider appeals.
(B) Except for OHCA Program Integrity audit
appeals, if the appropriate LD form is not received timely, the OHCA ALJ will
cause a letter to be issued stating that the appeal will not be
heard.
(C) A decision ordinarily
will be issued by the OHCA ALJ within forty-five (45) days of the close of all
evidence in the appeal.
(D) Unless
otherwise limited by OAC
317:2-1-7 or
317:2-1-13, the OHCA ALJ's
decision is appealable to OHCA's CEO, or his or her designated independent
ALJ.
(d)
OHCA ALJ jurisdiction. The OHCA ALJ has jurisdiction of the
following matters:
(1)
Member
appeals.
(A) Discrimination complaints
regarding the SoonerCare program;
(B) Appeals which relate to the scope of
services, covered services, complaints regarding service or care, enrollment,
disenrollment, and reenrollment in the SoonerCare program;
(C) Fee-for-service appeals regarding the
furnishing of services, including prior authorizations;
(D) Appeals which relate to the tax warrant
intercept system through the OHCA. Tax warrant intercept appeals will be heard
directly by the OHCA ALJ. A decision will be rendered by the OHCA ALJ within
twenty (20) days of the hearing;
(E) Proposed administrative sanction appeals
pursuant to OAC
317:35-13-7. Proposed
administrative sanction appeals will be heard directly by the OHCA ALJ. A
decision by the OHCA ALJ will ordinarily be rendered within twenty (20) days of
the hearing. This is the final and only appeals process for proposed
administrative sanctions;
(F)
Appeals which relate to eligibility determinations made by OHCA;
(G) Appeals of insureds participating in
Insure Oklahoma which are authorized by OAC
317:45-9-8;
(H) Appeals which relate to a requested step
therapy protocol exception as provided by 63 O.S. § 7310; and
(I) Requests for state fair hearing arising
from a member's appeal of a CE or DBM adverse benefit
determination.
(2)
Provider appeals.
(A) Whether
Pre-admission Screening and Resident Review (PASRR) was completed as required
by law;
(B) Denial of request to
disenroll member from provider's SoonerCare Choice panel;
(C) Appeals by long-term care facilities for
administrative penalty determinations as a result of findings made under OAC
317:30-5-131.2(b)(5)(B) and
(d)(8);
(D) Appeals of Professional Service Contract
awards and other matters related to the Central Purchasing Act pursuant to
Title 74 O.S. §
85.1 et seq.;
(E) Drug rebate appeals;
(F) Provider appeals of OHCA Program
Integrity audit findings pursuant to OAC
317:2-1-7. This is the final and
only appeals process for appeals of OHCA Program Integrity audit
findings;
(G) Oklahoma Electronic
Health Records Incentive program appeals related only to incentive payments,
incentive payment amounts, provider eligibility determinations, and
demonstration of adopting, implementing, upgrading, and meaningful use
eligibility for incentives;
(H)
Supplemental Hospital Offset Payment Program (SHOPP) annual assessment,
supplemental payment, fees, or penalties as specifically provided in OAC
317:2-1-15; and
(I) Appeals from any adjustment made to a
long-term care facility's cost report pursuant to OAC
317:30-5-132, including any
appeal following a request for reconsideration made pursuant to OAC
317:30-5-132.1.
Added at 13 Ok Reg 389,
eff 11-14-95 (emergency); Added at 13 Ok Reg 893, eff 11-21-95 (emergency);
Amended at 13 Ok Reg 2301, eff 4-10-96 (emergency); Added at 13 Ok Reg 1627,
eff 5-27-96; Amended at 13 Ok Reg 3179, eff 6-18-96 (emergency); Amended at 14
Ok Reg 1755, eff 5-27-97; Amended at 15 Ok Reg 3771, eff 6-24-98 (emergency);
Amended at 16 Ok Reg 1412, eff 5-27-99; Amended at 18 Ok Reg 243, eff 11-21-00
(emergency); Amended at 18 Ok Reg 758, eff 1-23-01 (emergency); Amended at 18
Ok Reg 2949, eff 5-17-01 (emergency); Amended at 19 Ok Reg 2120, eff 6-27-02;
Amended at 20 Ok Reg 1919, eff 6-269-03; Amended at 21 Ok Reg 2147, eff
6-25-04; Amended at 23 Ok Reg 761, eff 3-9-06 (emergency); Amended at 23 Ok Reg
2430, eff 6-25-06; Amended at 24 Ok Reg 300, eff 12-1-06 (emergency); Amended
at 24 Ok Reg 869, eff 5-11-07; Amended at 27 Ok Reg 702, eff 3-1-10 through
7-14-10 (emergency)1; Amended at 27 Ok Reg 2733, eff
7-20-10 (emergency); Amended at 28 Ok Reg 7, eff 8-13-10 (emergency); Amended
at 28 Ok Reg 259, eff 11-15-10 (emergency); Amended at 28 Ok Reg 1376, eff
6-25-11; Amended at 29 Ok Reg 187, eff 11-22-11 (emergency); Amended at 29 Ok
Reg 469, eff 5-11-12
1This emergency action expired
without being superseded by a permanent action. Upon expiration of an emergency
amendatory action, the last effective permanent text is reinstated. Therefore,
on 7-15-10 (after the 7-14-10 expiration of this emergency action), the text of
317:2-1-2 reverted back to the permanent text that became effective 5-11-07, as
last published in the 2009 OAC Supplement, and remained as such until amended
by emergency action on 7-20-10.