Okla. Admin. Code § 317:2-1-2 - Appeals
(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 representive, 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 managed care 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.
(J) Request for a State fair hearing arising
from provider's appeal of managed care audit findings, for-cause or immediate
termination of the provider's managed care contract, or managed care claims
denial.
Notes
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