Utah Administrative Code
Topic - Health
Title R410 - Health Care Financing
Rule R410-14 - Administrative Hearing Procedures
Section R410-14-2 - Definitions
Universal Citation: UT Admin Code R 410-14-2
Current through Bulletin 2024-06, March 15, 2024
(1) The definitions in Rule R414-1 and Section 63G-4-103 apply to this rule.
(2) The following definitions also apply:
(a) "Action" means:
(i) a denial, termination, suspension, or
reduction of medical assistance for a member;
(ii) a reduction, denial or revocation of
reimbursement for services for a provider;
(iii) a denial or termination of eligibility
for participation in a program, or as a provider;
(iv) a determination by skilled nursing
facilities and nursing facilities to transfer or discharge residents;
(v) an adverse determination, as defined in
Subsection (2)(b);
(vi) an adverse
benefit determination as defined in Subsection
R410-14-20(2)(a);
or
(vii) placement of a Medicaid
enrollee on the restriction program.
(b) "Adverse determination" means a
determination made in accordance with Subsection 1919(b)(3)(F) or Subsection
1919(e)(7)(B) of the Social Security Act that the individual does not require
the level of services provided by a nursing facility or that the individual
does or does not require specialized services.
(c) "Agency" means Division of Integrated
Healthcare (DIH) within the Department of Health and Human Services (DHHS), the
Department of Workforce Services (DWS), or any managed health care organization
(MCO) that has conducted or performed an action as defined in this
rule.
(d) "Aggrieved person" means
any member, enrollee, or provider who is affected by an action of an
agency.
(e) "CHEC" means Child
Health Evaluation and Care program, which is Utah's version of the federally
mandated Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
Medicaid child health program.
(f)
"De novo" means anew, or considering the question of a case for the first
time.
(g) "Department" means the
Department of Health and Human Services (DHHS).
(h) " DWS" means the Department of Workforce
Services.
(i) "Eligibility agency"
means DWS, DHHS, or any entity the agency contracts with to determine medical
assistance eligibility.
(j) "Ex
parte" communications mean direct or indirect communication in connection with
an issue of fact or law between the hearing officer and one party
only.
(k) "Grievance" means an
expression of dissatisfaction about any matter other than an action as defined
in this rule. Grievances may include the quality of care of services provided
and aspects of interpersonal relationships such as rudeness of a provider or
employee or failure to respect the rights of an enrollee of a managed care
organization (MCO).
(l) "Grievance
system" means the overall system that includes grievances and appeals handled
by an MCO and access to the administrative hearing process set out in this
rule.
(m) "Hearing officer" means
solely any person designated by the DIH Director to conduct administrative
hearings pursuant to this rule.
(n)
"Managed care organization" means a health maintenance organization, a prepaid
mental health plan, or a dental managed care plan that contracts with DIH to
provide health, behavioral health, or oral health services to Medicaid or
Children's Health Insurance Program members.
(o) "Medical record" means a record that
contains medical data of a medical assistance member or enrollee.
(p) "Provider" means any person or entity
that is licensed and otherwise authorized to furnish health care to medical
assistance members or medical assistance MCO enrollees.
(q) "Order" means a ruling by a hearing
officer that determines the legal rights, duties, privileges, immunities, or
other legal interests of one or more specific persons.
(r) "Scope of service" means medical, oral,
or behavioral health services set out under Title R414 as a covered
benefit.
(s) "State fair hearing"
means an administrative hearing conducted pursuant to this
rule.
Disclaimer: These regulations may not be the most recent version. Utah may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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