Mass. Gen. Laws ch. 118E, sec. 47 — MA Code / Part I / Title XVII / Chapter 118E / Section 47
Persons aggrieved; written notification of denial of requested benefits or services; right to hearing; investigation; decision; rehearing; notice
Status: in_force

Section 47. Any applicant for or recipient of medical assistance, or the legal representative of such applicant or recipient, aggrieved by the failure of the division to grant medical assistance or by the failure of the division to approve or reject an application within the time limits established by section twenty-one or by the withdrawal of such assistance shall have a right to a hearing, after due notice, upon appeal to the division in the manner and form prescribed by the division; provided, however, such appeal is received by the division within thirty days after official notice of the action taken by the division has been received by the applicant or recipient. Such hearing shall be conducted by the commissioner of medical assistance or a referee designated by the commissioner within the board of hearings established under section forty-eight. The commissioner or the designated referee is hereby empowered to subpoena witnesses, administer oaths, take testimony and secure the production of such books, papers, records and documents as may be relevant to such hearings. The decision of the commissioner, or of the designated referee, small be the decision of the division. Such appeals, hearings, and decisions shall be subject to the provisions of section forty-eight. Notwithstanding any general or special law to the contrary, the division shall promulgate regulations that require the division, its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract with the division, a Medicaid managed care organization or primary care clinician plan, to maintain documentation of all requests for benefits or services, whether the request is submitted by, or on behalf of, the intended recipient of those benefits or services. Any request that is not fulfilled in full shall be considered a denial and shall result in the prompt written notification to the intended recipient through electronic means, if possible. The notification shall include a description of the requested service, the response by the entity and the intended recipient's due process and appeal rights. All such entities shall accept requests for authorized representatives or for appeals by electronic means. The division may make such additional investigation as it may deem necessary and shall make such decision as to the granting of medical assistance and the amount of such assistance to be granted as in its opinion is justified and in conformity with the provisions of this chapter. Applicants or recipients affected by such decisions of the division shall, upon request, be given reasonable notice and opportunity for a hearing as provided under this section. The provisions relating to the conduct of hearings and decisions thereon made, as provided in this section, shall be equally applicable in all cases wherein the division acts upon its own motion. The commissioner, or the referee designated by the commissioner, shall render and issue his or her decision within ninety days after the date of the filing of the appeal by the aggrieved applicant, or legal representative of an applicant. The commissioner, but not his or her designee, may for good cause shown, direct the director of the board of hearings to conduct a rehearing of the appeal. An order for such rehearing shall not be construed as indicating or implying any position by the commissioner on the merits of the appeal. The director shall send seven days' written notice to all parties, including the date, time and place of such rehearing, which shall be held at a location convenient to the person appealing, and after such rehearing the director may, not later than thirty days after the order for such rehearing, issue a superseding decision.

Section 47. Any applicant for or recipient of medical assistance, or the legal representative of such applicant or recipient, aggrieved by the failure of the division to grant medical assistance or by the failure of the division to approve or reject an application within the time limits established by section twenty-one or by the withdrawal of such assistance shall have a right to a hearing, after due notice, upon appeal to the division in the manner and form prescribed by the division; provided, however, such appeal is received by the division within thirty days after official notice of the action taken by the division has been received by the applicant or recipient. Such hearing shall be conducted by the commissioner of medical assistance or a referee designated by the commissioner within the board of hearings established under section forty-eight. The commissioner or the designated referee is hereby empowered to subpoena witnesses, administer oaths, take testimony and secure the production of such books, papers, records and documents as may be relevant to such hearings. The decision of the commissioner, or of the designated referee, small be the decision of the division. Such appeals, hearings, and decisions shall be subject to the provisions of section forty-eight.

Notwithstanding any general or special law to the contrary, the division shall promulgate regulations that require the division, its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract with the division, a Medicaid managed care organization or primary care clinician plan, to maintain documentation of all requests for benefits or services, whether the request is submitted by, or on behalf of, the intended recipient of those benefits or services. Any request that is not fulfilled in full shall be considered a denial and shall result in the prompt written notification to the intended recipient through electronic means, if possible. The notification shall include a description of the requested service, the response by the entity and the intended recipient's due process and appeal rights. All such entities shall accept requests for authorized representatives or for appeals by electronic means.

The division may make such additional investigation as it may deem necessary and shall make such decision as to the granting of medical assistance and the amount of such assistance to be granted as in its opinion is justified and in conformity with the provisions of this chapter. Applicants or recipients affected by such decisions of the division shall, upon request, be given reasonable notice and opportunity for a hearing as provided under this section. The provisions relating to the conduct of hearings and decisions thereon made, as provided in this section, shall be equally applicable in all cases wherein the division acts upon its own motion.

The commissioner, or the referee designated by the commissioner, shall render and issue his or her decision within ninety days after the date of the filing of the appeal by the aggrieved applicant, or legal representative of an applicant. The commissioner, but not his or her designee, may for good cause shown, direct the director of the board of hearings to conduct a rehearing of the appeal. An order for such rehearing shall not be construed as indicating or implying any position by the commissioner on the merits of the appeal. The director shall send seven days' written notice to all parties, including the date, time and place of such rehearing, which shall be held at a location convenient to the person appealing, and after such rehearing the director may, not later than thirty days after the order for such rehearing, issue a superseding decision.