Current through Bulletin 2024-06, March 15, 2024
(1) Except as
provided in this rule or as otherwise designated by rule or statute or
converted pursuant to Subsection
63G-4-202(3),
all adjudicative proceedings conducted pursuant to this rule are informal
proceedings.
(2) An aggrieved
person may file a written request for agency action pursuant to Section
63G-4-201, and in accordance with
this rule.
(a) A provider may file a written
request for agency action without the consent of the member or MCO enrollee if
the request for agency action pertains to the denial of an authorization for
service or a denial of payment on a claim.
(b) A provider may not file a request for
agency action if the request for agency action pertains to the denial, change,
or termination of eligibility of a member or enrollee for a medical assistance
program.
(3) If a medical
issue is in dispute, each request must include supporting medical
documentation. DIH may schedule a hearing only when it receives sufficient
medical records and may dismiss a request for agency action if it does not
receive supporting medical documentation in a timely manner.
(4) An agency shall provide a written notice
of action to each aggrieved person. These actions include:
(a) eligibility for assistance;
(b) scope of service;
(c) denial or limited prior authorization of
a requested service including the type or level of service; and
(d) payment of a claim.
(5) The notice must include:
(a) a statement of the action the agency
intends to take;
(b) the date the
intended action becomes effective;
(c) the reasons for the intended
action;
(d) the specific
regulations that support the action, or the change in federal law, state law or
DIH policy which requires the action;
(e) the right to request a hearing;
(f) the right to represent oneself, the right
to legal counsel, or the right to use another representative at the hearing;
and
(g) if applicable, an
explanation of the circumstances under which reimbursement for medical services
will continue or may be reinstated pursuant to this rule.
(6) The agency shall mail the notice at least
ten calendar days before the date of the intended action except:
(a) the agency may mail the notice before the
date of action in accordance with
42 CFR
431.213;
(b) the agency may shorten the period of
advance notice to five days before the date of action if it has facts that
indicate it must take action due to probable fraud by the member or provider
and the facts have been verified by affidavit.
