reglab/statecodes huggingface dataset:
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-2.5 - Expedited appeals

Current through Vol. 41, No. 20, July 1, 2024
(a) An Appellant
				may request an expedited hearing, if the time otherwise permitted for a hearing
				as described in Oklahoma Administrative Code (OAC)
				317:2-1-2(b)(8)
				could jeopardize the Appellant's life or health or ability to attain, maintain,
				or regain maximum function. Any request for expedited consideration should be
				made to the Administrative Law Judge (ALJ), with a copy to the Oklahoma Health
				Care Authority (OHCA) Legal division and shall be ruled upon within three (3)
				working days of the date of the request. The request shall specify the reason
				for the appeal and the specific basis for the Appellant's assertion that a
				delay will jeopardize the Appellant's life or health.
(b) If the ALJ determines that an expedited
				hearing is warranted, he or she shall:
(1)
				Schedule the matter for hearing pursuant to OAC
				317:2-1-5.
				Telephonic hearings may be scheduled as appropriate under the particular facts
				of the case; and
(2) Issue a
				preliminary or final decision as expeditiously as possible, but no later than
				three (3) working days the close of the expedited hearing.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-2.6 - Continuation of benefits or services pending appeal

Current through Vol. 41, No. 20, July 1, 2024
(a) In accordance
				with Section 431.230 of Title 42 of the Code of Federal Regulations, if an
				Appellant submits a written request for a hearing within ten (10) days of the
				notice of the adverse agency action, the Appellant may also request that
				existing benefits or services (hereinafter, collectively referred to as
				"services") be continued or reinstated until the earlier of dismissal of the
				appeal, Appellant's withdrawal of the appeal, or an initial hearing decision
				adverse to the Appellant.
(b) If
				the Appellant fails to indicate a preference as to continuation or
				reinstatement of services in a written request for hearing made within ten (10)
				days of the notice of the adverse agency action, services shall be continued or
				reinstated. Provided, however, that a SoonerCare member shall not be entitled
				to continuation or reinstatement of services pending an appeal related to the
				following:
(1) When a service is denied
				because the member has exceeded the limit applicable to that service;
(2) When a request for a prior
				authorization is denied for a prescription drug. However:
(A) The Oklahoma Health Care Authority (OHCA)
				may authorize a single seventy-two (72) hour emergency supply of the drug, in
				accordance with Oklahoma Administrative Code (OAC)
				317:30-5-77.2;
(B) A SoonerCare provider may
				initiate a step therapy exception request on behalf of a member, in accordance
				with OAC 317:30-5-77.4;
(3) When coverage of a prescription drug or
				service is denied because the requested drug or service is not a category or
				class of drugs or services covered by OHCA;
(4) When coverage for a prescription drug is
				denied because the enrollee has been locked into one (1) pharmacy and the
				member seeks to fill a prescription at another pharmacy; or
(5) When a physician or other licensed health
				care practitioner has failed to prescribe or order the service or level of
				service for which continuation or reinstatement is requested.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-2.6 - Continuation of benefits or services pending appeal

Current through Vol. 41, No. 20, July 1, 2024
(a) In accordance
				with Section
				431.230 of Title 42 of the Code of
				Federal Regulations, if an appellant submits a written request for a hearing
				within sixty (60) days of the notice of the adverse Agency action, the
				appellant may also request that existing benefits or services (hereinafter,
				collectively referred to as "services") be continued or reinstated until the
				earlier of dismissal of the appeal, appellant's withdrawal of the appeal, or an
				initial hearing decision adverse to the appellant.
(b) If the appellant fails to indicate a
				preference as to continuation or reinstatement of services in a written request
				for hearing made within sixty (60) days of the notice of the adverse Agency
				action, services shall be continued or reinstated. Provided, however, that a
				SoonerCare member shall not be entitled to continuation or reinstatement of
				services pending an appeal related to the following:
(1) When a service is denied because the
				member has exceeded the limit applicable to that service;
(2) When a request for a prior authorization
				is denied for a prescription drug. However:
(A) The Oklahoma Health Care Authority (OHCA)
				may authorize a single seventy-two (72) hour emergency supply of the drug, in
				accordance with Oklahoma Administrative Code (OAC)
				317:30-5-77.2;
(B) A SoonerCare provider may initiate a step
				therapy exception request on behalf of a member, in accordance with OAC
				317:30-5-77.4;
(3) When coverage of a prescription drug or
				service is denied because the requested drug or service is not a category or
				class of drugs or services covered by OHCA;
(4) When coverage for a prescription drug is
				denied because the Enrollee has been locked into one (1) pharmacy and the
				member seeks to fill a prescription at another pharmacy; or
(5) When a physician or other licensed health
				care practitioner has failed to prescribe or order the service or level of
				service for which continuation or reinstatement is
				requested.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-3 - Drug rebate appeals [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 13 Ok Reg 893,
				  eff 11-21-95 (emergency); Revoked at 13 Ok Reg 2301, eff 4-10-96 (emergency);
				  Added at 13 Ok Reg 1627, eff 5-27-96; Revoked at 14 Ok Reg 1755, eff
				  5-27-97
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-4 - Appeal to the Chief Executive Officer [REVOKED]

Current through Vol. 41, No. 20, July 1, 2024
Added at 13 Ok Reg 3559,
				  eff 7-16-96 (emergency); Added 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 2951, eff 4-24-01 (emergency); Amended at 19 Ok Reg 2120,
				  eff 6-27-02; Amended at 20 Ok Reg 2756, eff 5-26-03 (emergency); Amended at 21
				  Ok Reg 1318, eff 5-27-04; Revoked at 23 Ok Reg 761, eff 3-9-06 (emergency);
				  Revoked at 23 Ok Reg 2430, eff 6-25-06
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-5 - Hearing procedures

Current through Vol. 41, No. 20, July 1, 2024
(a) Hearings
				will be conducted in an informal manner without formal rules of evidence or
				procedure, except for hearings under
				317:2-1-7.
(b) No party is required to be represented by
				an attorney. Members may represent themselves or authorize another party to
				represent them. A person or entity desiring to represent a member must provide
				documentation of the consent of the member to be represented by that person or
				entity. An appeal will be rejected without documentation of representation.
				Individuals appearing for corporate entities will be deemed to be authorized to
				represent the corporation in a hearing.
(c) The docket clerk will send the Appellant
				and any other necessary party notice which states the hearing location, date,
				and time.
(d) The OHCA
				Administrative Law Judge or designee may:
(1)
				Rule on any requests for extension of time;
(2) Hold pre-hearing conferences to settle,
				simplify, or identify issues in a proceeding or to consider other matters that
				may end in the expeditious disposition of the proceeding;
(3) Require the parties to state their
				positions concerning the various issues in the proceeding;
(4) Require the parties to produce for
				examination those relevant witnesses and documents under their
				control;
(5) Rule on motions and
				other procedural items;
(6)
				Regulate the course of the hearing and conduct of the participants;
(7) Establish time limits for the submission
				of motions or memoranda;
(8) Impose
				appropriate sanctions against any person failing to obey an order of the ALJ or
				authorized under the rules in this Chapter which may include:
(A) Refusing to allow the person to assert or
				oppose designated claims or defenses, or prohibiting that person from
				introducing designated matters in evidence;
(B) Excluding all testimony of an
				unresponsive or evasive witness; or
(C) Expelling the person from further
				participation in the hearing;
(9) Take official notice of any material fact
				not appearing as evidence in the record, if the fact is among traditional
				matters of judicial notice;
(10)
				Administer oaths or affirmations;
(11) Determine the location of the
				hearing;
(12) Allow either party to
				request that the hearing be recorded by a court reporter with costs to be borne
				by the requesting party. The original of such transcription, if ordered, will
				be given to the ALJ with a copy to be given to the requesting party;
(13) Recess and reconvene the
				hearing;
(14) Set and/or limit the
				time frame of the hearing;
(15)
				Reconsider or rehear a matter for good cause shown; and
(16) Send a copy of the decision by the ALJ
				to both parties outlining their rights to appeal the decision. The decision
				letter need not contain findings of fact or conclusions of law.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-6 - Other grievance procedures and processes [Revoked]

Current through Vol. 41, No. 20, July 1, 2024
Added at 23 Ok Reg 761,
				  eff 3-9-06 (emergency); Added at 23 Ok Reg 2430, eff 6-25-06; Amended at 26 Ok
				  Reg 3020, eff 7-21-09 (emergency); Amended at 27 Ok Reg 925, eff 5-13-10;
				  Amended at 27 Ok Reg 2733, eff 7-20-10 (emergency); Amended at 28 Ok Reg 259,
				  eff 11-15-10 (emergency); Amended at 28 Ok Reg 1376, eff
				  6-25-11
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-7 - Program Integrity Audit Appeals

Current through Vol. 41, No. 20, July 1, 2024
All appeals related to audits originating from Program
				  Integrity resulting in overpayments are heard by an Administrative Law Judge
				  (ALJ) pursuant to 56 Oklahoma Statutes (O.S.) § 1011.9.
(1) If the Oklahoma Health Care Authority
				(OHCA) determines a provider received an overpayment based upon audit
				findings/report issued pursuant to Oklahoma Administrative Code (OAC)
				317:30-3-2.1, the provider may
				appeal the audit findings/report. If a provider elects to appeal the audit
				findings/report, the provider must file its appeal with the OHCA's Legal Docket
				Clerk, using Form LD-2. The LD-2 must be received by the OHCA Legal Docket
				Clerk within thirty (30) calendar days of the date of the initial audit
				findings/report or within thirty (30) calendar days of the date of the
				reconsideration audit findings/report. The computation of time shall be
				calculated in accordance with OAC
				317:2-1-2(a).
(2) The provider must attach a statement to
				the LD-2 that specifies what findings and/or claims are being appealed, as well
				as all factual and legal bases for the appeal. The provider shall attach the
				following to the LD-2 form:
(A) Citations for
				any statute or rule that the provider contends has been violated;
(B) The provider's name, address, e-mail
				address, and telephone number;
(C)
				The name, address, e-mail address, and telephone number of the provider's
				authorized representative, if any; and
(D) The LD-2 must be signed by the provider
				or provider's authorized representative.
(i)
				For purposes of this section, "provider" means the person or entity against
				whom the overpayment is sought.
(ii) Consistent with Oklahoma rules of
				practice, an individual provider may appear on his/her own behalf or may be
				represented by an attorney licensed to practice law within the State of
				Oklahoma. In the case of an entity, the provider entity must be represented by
				an attorney licensed to practice within the State of Oklahoma. Attorneys not
				licensed to practice in Oklahoma must comply with 5 O.S. Art II, Sec. 5, and
				rules of the Oklahoma Bar Association.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-8

Current through Vol. 41, No. 20, July 1, 2024
Added at 23 Ok Reg 761,
				  eff 3-9-06 (emergency); Added at 23 Ok Reg 2430, eff 6-25-06; Amended at 26 Ok
				  Reg 3020, eff 7-21-09 (emergency); Amended at 27 Ok Reg 925, eff
				  5-13-10
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-9 - OHCA's Designated Agent's appeal process for QIO Decisions

Current through Vol. 41, No. 20, July 1, 2024
The OHCA's Quality Improvement Organization (QIO) conducts an
				  administrative process for those providers it reviews. The process afforded
				  providers by QIO is the only administrative remedy available to providers. The
				  decision issued by the QIO is considered by the OHCA to be a final
				  administrative determination. The final QIO determination is not appealable to
				  the OHCA for any further administrative hearings. After the QIO'S decision,
				  OHCA will recoup the monies paid the provider related to the
				  review.
Added at 23 Ok Reg 761,
				  eff 3-9-06 (emergency); Added at 23 Ok Reg 2430, eff 6-25-06; Amended at 26 Ok
				  Reg 3020, eff 7-21-09 (emergency); Amended at 27 Ok Reg 925, eff
				  5-13-10
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-10 - Drug Rebate appeal process

Current through Vol. 41, No. 20, July 1, 2024
The purpose of this Section is to afford a process to both
				  the manufacturer and the state to administratively resolve drug rebate
				  discrepancies. These rules anticipate discrepancies between the manufacturer
				  and the Oklahoma Health Care Authority (OHCA) which would require the
				  manufacturer to pay a higher rebate or a lower rebate. These regulations
				  provide a mechanism for both informal dispute resolution of drug rebate
				  discrepancies between the manufacturer and OHCA and a mechanism for appeals of
				  drug rebate discrepancies between the manufacturer and OHCA.
(1) The process begins at the end of each
				calendar quarter when the OHCA mails a copy of the State's past quarter's
				utilization data to the manufacturer. Utilization data and a billing for
				rebates will be mailed to the manufacturer within sixty (60) days after the end
				of each quarter. It is this data which dictates the application of the federal
				drug rebate formula.
(2) Within
				thirty (30) days from the date utilization data is sent to the manufacturer,
				the manufacturer may edit state data and resolve data inconsistencies with the
				state. The manufacturer may utilize telephone conferences, letters and any
				other mechanism to resolve data inconsistencies in mutual agreement with the
				state.
(3) Within thirty (30) days
				after the utilization data is mailed to the manufacturer, the manufacturer may:
(A) pay the same amount as billed by the
				state with the quarterly utilization date;
(B) pay an amount which differs from the
				amount billed by the state with the utilization data and send disputed data
				information;
(C) pay nothing and
				send no disputed data information;
(D) pay nothing and send disputed data
				information.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-12 - For cause and immediate provider contract termination appeals process

Current through Vol. 41, No. 20, July 1, 2024
This section explains the appeals process for providers
				  whose SoonerCare contracts have been terminated by the Oklahoma Health Care
				  Authority (OHCA) for cause.
(1)
Thirty (30) day for cause termination.
Pursuant to the terms of
				all provider contracts with the OHCA, either party may terminate the contract
				for cause with a thirty (30) day written notice to the other party.
(A)
Notice of proposed
				termination.
The OHCA will provide notice to the provider of the
				proposed termination of the provider's contract. The written notice of
				termination will state:
(i) the reasons for
				the proposed termination;
(ii) the
				date upon which the termination will be effective; and
(iii) a statement that the provider has a
				right to OHCA review prior to the termination of the provider's
				contract.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-13 - Appeal to the chief executive officer

Current through Vol. 41, No. 20, July 1, 2024
(a) The Oklahoma Health Care Authority offers
				approximately forty (40) different types of administrative appeals. Some of the
				appeals are appealable to the chief executive officer (CEO) and some are not.
				The following appeals are subject to further review upon timely submission of a
				request for CEO appeal and may be reviewed by the CEO, or his or her designated
				independent administrative law judge (ALJ), following the decision of the OHCA
				ALJ:
(1) Appeals under Oklahoma
				Administrative Code (OAC)
				317:2-1-2(d)(1)(A)
				to (d)(1)(H), with the exception of
				subsection (d)(1)(E); and
(2)
				Appeals under OAC
				317:2-1-2(d)(2)(A)
				to (d)(2)(I), with the exceptions of
				subsections (d)(2)(D),(E),(F),(G), and (I).
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-14 - Contract award protest process

Current through Vol. 41, No. 20, July 1, 2024
(a)
Protest process.
Suppliers who respond to a solicitation issued
				and awarded by the Authority pursuant to 74 Oklahoma Statutes (O.S.) §
				85.5 (N) may protest the award of a contract under such solicitation to the
				State Purchasing Director. All remedies available to suppliers through the
				sealed bid process pursuant to the Oklahoma Central Purchasing Act are also
				available to online bidders in an online bidding process.
(b)
State Purchasing Director review
				and determination.
The State Purchasing Director will review the
				supplier's protest and contract award documents.
(1) The State Purchasing Director may
				determine to respond to the protest or delegate the responsibility to OHCA by
				written notice to OHCA.
(2) The
				State Purchasing Director or OHCA, as applicable, will send to the supplier
				written notice of the decision to deny or sustain the protest within ten (10)
				business days of receipt of the protest.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-15 - Supplemental Hospital Offset Payment Program (SHOPP) Appeals

Current through Vol. 41, No. 20, July 1, 2024
(a) In accordance
				with Title 63 of the Oklahoma Statutes Section
				3241.4
				OHCA is authorized to promulgate rules for appeals of annual assessments, fees
				and penalties to hospitals as defined by the statute. The rules in this Section
				describe those appeals rights.
(1) OAC
				317:30-5-58
				subsections (a) through (e) describe the SHOPP Assessments, fees and the
				penalties for non-payment of the fee or failure to file a cost report, as set
				out in 63 Okla. Stat. §§ 3241.3 and 3241.4
(2) Appeals filed under this Section are
				heard by an Administrative Law Judge (ALJ).
(3) To file an appeal, the provider hospital
				must file an LD-2 form within thirty (30) days of receipt of the notification
				from OHCA assessing the annual SHOPP Assessment, a fee or penalty. The penalty,
				fee or assessment is deducted from the hospital's payment if the assessment is
				unpaid at the time the appeal is filed. If the hospital prevails in the appeal
				the amount assessed will be returned to the hospital with their
				payment.
(4) The hearing will be
				conducted in accordance with OAC
				317:2-1-5.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-17 - Long-term care facility cost report appeals

Current through Vol. 41, No. 20, July 1, 2024
This rule describes a long-term facility's rights to
				  administratively appeal any cost adjustment(s) made by the Oklahoma Health Care
				  Authority (OHCA) to the facility's annual cost report, in accordance with the
				  Oklahoma Administrative Code (OAC)
				  317:30-5-132,
				  or any cost report reconsideration, in accordance with OAC
				  317:30-5-132.1.
(1) The following are appealable
				issues of the program:
(A) Any disputed
				adjustment(s) that are made by the OHCA to the facility's annual cost report,
				in accordance with OAC
				317:30-5-132(5);
				or
(B) Any disputed cost report
				adjustment reconsideration decision, made by OHCA's chief financial officer or
				his/her designee in accordance with OAC
				317:30-5-132.1.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-18 - Step therapy protocol exception appeals

Current through Vol. 41, No. 20, July 1, 2024
This rule describes a member's rights to administratively
				  appeal the denial of a requested exception to a step therapy protocol, in
				  accordance with Title 63 of the Oklahoma Statutes (O.S.) §
									7310 and Oklahoma Administrative
				  Code (OAC) 317:30-5-77.4.
(1) Appeals
				will be heard by the Oklahoma Health Care Authority (OHCA) administrative law
				judge (ALJ).
(2) Appeals must be
				filed by the member within thirty (30) days of the date of the denial of a
				requested exception. Appeals must be filed electronically using a form LD-5 and
				must set forth the basis for the appeal. The form LD-5 shall be made available
				on the OHCA's public website. If the LD-5 is not completely filled out or if
				necessary documentation is not included, the appeal will not be considered.
(3) Appeals shall be heard at a
				time and place and in a manner as may be decided by the ALJ. Hearings may be
				conducted telephonically.
(4) The
				docket clerk will send the member or his/her authorized representative an
				electronic notice setting forth the location, date, and time of the hearing.
(5) A member can waive the right
				to an evidentiary hearing and permit the ALJ to consider and rule on the appeal
				based upon the parties' submissions.
(6) The member shall have the burden of proof
				by the preponderance of the evidence standard as defined by the Oklahoma
				Supreme Court.
(7) Absent exigent
				circumstances, as defined in OAC 317:30-5-77.4(a), the ALJ shall respond to any
				request for appeal within seventy-two (72) hours of receipt of the request. In
				the case of exigent circumstances, the ALJ shall respond within twenty-four
				(24) hours of receipt. Provided, however, that if the timeframe for response
				ends on a weekend, or on any other day the OHCA is closed or closes early,
				including, but not limited to, legal holidays as defined by 25 O.S. §
				82.1, the timeframe for response shall run until the close of the next full
				business day. An appeal request that is not responded to within this timeframe
				shall be deemed granted.
(8) All
				orders shall be considered non-precedential decisions.
(9) The hearing shall be digitally recorded.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-2 - Timeframes

Current through Vol. 41, No. 20, July 1, 2024
(a) For the purpose
				of calculating a timeframe in this Subchapter, the date on the written notice
				is not included. The last day of the timeframe is included, unless the last day
				is a legal holiday, as defined by 25 Oklahoma Statutes (O.S.) § 82.1, or
				any other day OHCA is closed or closes early, in which case, the timeframe runs
				until the close of the next full business day.
(b) A grievance or appeal a member sends via
				mail is deemed filed on the date the MCE receives request.
(c) A request for reconsideration or appeal a
				provider sends via mail is deemed filed on the date the MCE receives the
				request.
(d) A request for State
				fair hearing by a member or provider is deemed filed on the date the OHCA
				receives the request.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-2 - Timeframes

Current through Vol. 41, No. 20, July 1, 2024
(a) For the purpose
				of calculating a timeframe in this Subchapter, the date on the written notice
				is not included. The last day of the timeframe is included, unless the last day
				is a legal holiday, as defined by 25 O.S. § 82.1, or any other day OHCA is
				closed or closes early, in which case, the timeframe runs until the close of
				the next full business day.
(b) A
				grievance or appeal a member sends via mail is deemed filed on the date the CE
				receives request.
(c) A request for
				reconsideration or appeal a provider sends via mail is deemed filed on the date
				the CE receives the request.
(d) A
				request for state fair hearing by a member or provider is deemed filed on the
				date the OHCA receives the request.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-3 - Grievance and appeals system

Current through Vol. 41, No. 20, July 1, 2024
In accordance with state and federal law, including but not
				  limited to 63 Oklahoma Statutes (O.S.) § 7310 and
				  42 Code of Federal
				  Regulations (C.F.R.) §§
										438.210,
				  431.213-14,
				  438.402,
				  438.404,
				  438.408,
				  and
				  438.410,
				  each MCE will have an established grievance and appeals system by which to
				  receive, process, and resolve grievances and appeals, including requests for
				  extensions of relevant timeframes, and by which to afford parties proper
				  notice.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-3 - Grievance and appeals system

Current through Vol. 41, No. 20, July 1, 2024
In accordance with state and federal law, including but not
				  limited to 63 O.S. § 7310 and
				  42 C.F.R. §§
										438.210,
				  431.213-14,
				  438.402,
				  438.404,
				  438.408, and
				  438.410, each CE and DBM will have
				  an established grievance and appeals system by which to receive, process, and
				  resolve grievances and appeals, including requests for extensions of relevant
				  timeframes, and by which to afford parties proper notice.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-4 - Member grievances

Current through Vol. 41, No. 20, July 1, 2024
(a)
Filing.
(1)
Filing with
				managed care entity.
Except as described in this section, when the
				member is enrolled in a managed care program, the member initially files a
				grievance with the managed care entity in which the member is
				enrolled.
(2)
Exception:
				Filing with OHCA.
When the member is enrolled in a managed care program
				and the grievance deals with direct interaction with OHCA or its employees or
				officers, the member first files the grievance with OHCA as an administrative
				appeal pursuant to applicable rules set forth at Oklahoma Administrative Code
				(OAC)
				317:2-1-2
				et seq.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-4 - Member grievances

Current through Vol. 41, No. 20, July 1, 2024
(a)
Filing.
(1)
Filing with a
				CE or DBM.
Except as described in this Section, when the member is
				enrolled in a managed care program, the member initially files a grievance with
				the CE or DBM in which the member is enrolled.
(2)
Exception: Filing with OHCA.
When the member is enrolled in a SoonerSelect program and the grievance deals
				with direct interaction with OHCA or its employees or officers, the member
				first files the grievance with OHCA as an administrative appeal pursuant to
				applicable rules set forth at OAC
				317:2-1-2 et
				seq.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-5 - Member appeals

Current through Vol. 41, No. 20, July 1, 2024
(a)
Filing.
(1)
Filing with
				managed care entity.
Except as described in this Section, when the
				member is enrolled in a managed care program, the member initially files an
				appeal with the managed care entity in which the member is enrolled.
(2)
Exception: Filing with OHCA.
When the member is enrolled in a managed care program, the member initially
				files administrative appeals with OHCA and follows the appeals rules set forth
				at Oklahoma Administrative Code (OAC)
				317:2-1-2
				et seq. whenever the appeal concerns a decision the Oklahoma Health Care
				Authority (OHCA) made regarding:
(A)
				Eligibility for Oklahoma Medicaid;
(B) Eligibility for a managed care
				program;
(C) Enrollment into
				Oklahoma Medicaid;
(D) Enrollment,
				including use of an auto-assignment algorithm, into a managed care
				entity;
(E) Disenrollment from a
				managed care entity; or
(F) Any
				other matter, so long as OHCA made the decision in the
				matter.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-5 - Member appeals

Current through Vol. 41, No. 20, July 1, 2024
(a)
Filing.
(1)
Filing with a
				CE or DBM.
Except as described in this Section, when the member is
				enrolled in a managed care program, the member initially files an appeal with
				the CE or DBM in which the member is enrolled.
(2)
Exception: Filing with OHCA.
When the member is enrolled in a SoonerSelect program, the member initially
				files administrative appeals with OHCA and follows the appeals rules set forth
				at OAC 317:2-1-2 et seq. whenever the
				appeal concerns a decision the OHCA made regarding:
(A) Eligibility for Oklahoma
				Medicaid;
(B) Eligibility for a
				SoonerSelect program;
(C)
				Enrollment into Oklahoma Medicaid;
(D) Enrollment, including use of an
				auto-assignment algorithm, into a CE or DBM;
(E) Disenrollment from a CE or DBM; or
(F) Any other matter, so long as
				OHCA made the decision in the matter.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-5.1 - Continuation of benefits pending appeal and state fair hearing

Current through Vol. 41, No. 20, July 1, 2024
(a) Per OAC
				317:2-1-2.6 and
				42 C.F.R. §
										438.420, the CE or DBM shall continue a
				member's benefits under the plan when all of the following occur:
(1) The member files the request for an
				appeal within sixty (60) calendar days following the date on the adverse
				benefit determination notice in accordance with
				42 C.F.R. §
											438.402(c)(1)(ii) and
				(c)(2)(ii):
(2) The appeal involves the termination,
				suspension, or reduction of previously authorized services;
(3) The services were ordered by an
				authorized provider;
(4) The period
				covered by the original authorization has not expired; and
(5) The member timely files for continuation
				of benefits, meaning on or before the later of the following:
(A) Within ten (10) calendar days of the CE
				or DBM sending the notice of adverse benefit determination; or
(B) The intended effective date of the CE or
				DBM's proposed adverse benefit determination.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-6 - External medical review and clinical expertise

Current through Vol. 41, No. 20, July 1, 2024
(a)
No
				external medical review.
The Oklahoma Health Care Authority (OHCA) will
				not offer an external medical review for the purposes of grievances or
				appeals.
(b)
Clinical
				expertise standards.
Individuals making the decision for a grievance or
				appeal regarding an adverse benefit determination will be unbiased with
				appropriate clinical expertise in treating the member's condition or disease.
(1) Medical review staff of the MCE will be
				licensed or credentialed health care clinicians with relevant clinical training
				and/or experience.
(2) All MCEs
				will use medical review staff for such appeals and shall not use any automated
				claim review software or other automated functionality for such
				appeals.
(3) Bias is deemed to
				exist if an individual making a decision on a grievance or appeal was involved
				in, or a subordinate of any individual involved in, any previous level of
				review or decision regarding the subject matter of the grievance or
				appeal.
(4) Clinical expertise is
				deemed necessary for decisions makers whenever:
(A) The denial is based on a lack of medical
				necessity;
(B) The grievance is
				regarding a denial of an expedited resolution an appeal; and
(C) The grievance or appeal involves clinical
				issues.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-6 - External medical review and clinical expertise

Current through Vol. 41, No. 20, July 1, 2024
(a)
External
				medical review.
The OHCA will not offer an external medical review for
				the purposes of grievances or appeals.
(b)
Clinical expertise
				standards.
Individuals making the decision for a grievance or appeal
				regarding an adverse benefit determination will be unbiased with appropriate
				clinical expertise in treating the member's condition or disease.
(1) Medical review staff of the CE and DBM
				will be licensed or credentialed health care clinicians with relevant clinical
				training and/or experience.
(2) All
				CE and DBM will use medical review staff for such appeals and shall not use any
				automated claim review software or other automated functionality for such
				appeals.
(3) Bias is deemed to
				exist if an individual making a decision on a grievance or appeal was involved
				in, or a subordinate of any individual involved in, any previous level of
				review or decision regarding the subject matter of the grievance or
				appeal.
(4) Clinical expertise is
				deemed necessary for decisions makers whenever:
(A) The denial is based on a lack of medical
				necessity;
(B) The grievance is
				regarding a denial of an expedited resolution an appeal; and
(C) The grievance or appeal involves clinical
				issues.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-7 - Obligation to pay costs of services

Current through Vol. 41, No. 20, July 1, 2024
(a) In accordance
				with
				42
				Code of Federal Regulations (C.F.R.) §
										438.420(d), the MCE may
				recover from the member the costs of services provided to the member while an
				appeal or State fair hearing is pending:
(1)
				To the extent the services were continued solely due to the requirements set
				forth in
				42
				C.F.R. §§
											438.420 or
				431.230(b);
				and
(2) The final resolution of the
				appeal or State fair hearing upholds the MCE's adverse benefit
				determination.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-7 - Obligation to pay costs of services

Current through Vol. 41, No. 20, July 1, 2024
(a) In accordance
				with 42 C.F.R. §
										438.420(d), the CE and DBM
				may recover from the member the costs of services provided to the member while
				an appeal or state fair hearing is pending:
(1) To the extent the services were continued
				solely due to the requirements set forth in
				42 C.F.R. §§
											438.420 or
				431.230(b);
				and
(2) The final resolution of the
				appeal or state fair hearing upholds the CE or DBM's adverse benefit
				determination.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-8 - Grievances and appeals notice

Current through Vol. 41, No. 20, July 1, 2024
(a) The MCE will
				provide timely written notices per OAC 317:2-3-4 and 317:2-3-5.
(b) Each notice will conform to the
				provisions of
				42 Code of Federal Regulations (C.F.R.)
				§
										438.10 related to information provided
				from an MCE to a member.
(c) At
				minimum, each notice will:
(1) Be written in
				a manner and format that may be easily understood and is readily accessible by
				members;
(2) Use OHCA-developed
				definitions for terms as those terms are defined in the Model Member Handbook
				related to the contract;
(3) Use a
				font size no smaller than twelve-point (12-point);
(4) Be made available in alternative formats
				and through the provision of auxiliary aids and services in an appropriate
				manner that takes into consideration the special needs of members with
				disabilities or limited English proficiency; and
(5) Include a large-print tagline, in minimum
				eighteen-point (18-point) font, and information on how to request auxiliary
				aids and services, including the provision of materials in alternative
				formats.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-8 - Grievances and appeals notice

Current through Vol. 41, No. 20, July 1, 2024
(a) The CE and DBM
				will provide timely written notices per OAC
				317:2-3-4 and
				317:2-3-5.
(b) Each notice will conform to the
				provisions of 42 C.F.R.
				§
										438.10 related to information provided
				from an CE and DBM to a member.
(c)
				At minimum, each notice will:
(1) Be written
				in a manner and format, as outlined in the Contract, that may be easily
				understood and is readily accessible by members;
(2) Use OHCA-developed definitions for terms
				as those terms are defined in the Enrollee Handbook related to the Contract;
(3) Use a font size no smaller
				than twelve-point (12-point);
(4)
				Be made available in alternative formats and through the provision of auxiliary
				aids and services in an appropriate manner that takes into consideration the
				special needs of members with disabilities or limited English proficiency; and
(5) Include a large-print tagline,
				in minimum eighteen-point (18-point) font, and information on how to request
				auxiliary aids and services, including the provision of materials in
				alternative formats.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-9 - Exhaustion of managed care entity appeals

Current through Vol. 41, No. 20, July 1, 2024
(a)
Deemed
				exhaustion of MCE appeals.
If the MCE fails to adhere to any timing or
				notice requirements as detailed in
				42 C.F.R.
				§
										438.408, the member is deemed to have
				exhausted the MCE's appeal process, and the member or the member's authorized
				representative may request a State fair hearing.
(b)
Actual exhaustion of MCE
				appeals.
Except as allowed in (a), a member or the member's authorized
				representative may request a State fair hearing only after receiving notice
				from the MCE upholding an adverse benefit determination and only within one
				hundred twenty (120) days after the date of the notice of appeal
				resolution.
(c)
Exhaustion of
				MCE appeals, determination.
OHCA has sole authority to decide whether
				MCE appeals have been exhausted for any member. Documentation, as submitted to
				OHCA by the MCE within fifteen (15) calendar days of the request for State fair
				hearing, will serve as evidence to deemed exhaustion, actual exhaustion, or no
				exhaustion of the MCE appeals process.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-9 - Exhaustion of CE or DBM appeals

Current through Vol. 41, No. 20, July 1, 2024
(a)
Deemed
				exhaustion of CE or DBM appeals.
If the CE and DBM fails to adhere to
				any timing or notice requirements as detailed in
				42 C.F.R. §
										438.408, the member is deemed to have
				exhausted the CE's or DBM's appeal process, and the member or the member's
				authorized representative may request a state fair hearing.
(b)
Actual exhaustion of CE or DBM
				appeals.
Except as allowed in (a), a member or the member's authorized
				representative may request a state fair hearing only after receiving notice
				from the CE and DBM upholding an adverse benefit determination and only within
				one hundred twenty (120) days after the date of the notice of appeal
				resolution.
(c)
Exhaustion of
				CE or DBM appeals, determination.
OHCA has sole authority to decide
				whether CE and DBM appeals have been exhausted for any member. Documentation,
				as submitted to OHCA by the CE and DBM within fifteen (15) calendar days of the
				request for state fair hearing, will serve as evidence to deemed exhaustion,
				actual exhaustion, or no exhaustion of the CE and DBM appeals
				process.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-10 - Provider complaint system

Current through Vol. 41, No. 20, July 1, 2024
(a) A participating
				provider or nonparticipating provider may file a complaint whenever:
(1) The provider is not satisfied with the
				MCE's policies and procedures; or
(2) The provider is not satisfied with a
				decision made by the MCE that does not impact the provision of services to
				members.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-10 - Provider complaint system and appeal requests

Current through Vol. 41, No. 20, July 1, 2024
(a) A participating
				provider or nonparticipating provider may file a complaint whenever:
(1) The provider is not satisfied with the
				CE's or DBM's policies and procedures; or
(2) The provider is not satisfied with a
				decision made by the CE and DBM that does not impact the provision of services
				to members.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-11 - Recordkeeping

Current through Vol. 41, No. 20, July 1, 2024
In compliance with
				  42 C.F.R. §
										438.3(h) and (u), the MCE
				  will maintain records of each grievance and appeal for ten (10) years after the
				  later of the final date of the contract period or the date of completion of any
				  MCE audit by the State, the Centers for Medicare and Medicaid Services (CMS),
				  the Office of the Inspector General, or the Comptroller General. Such records
				  will be part of OHCA's ongoing monitoring and will be used to update and revise
				  OHCA's managed care quality strategy. The record will conform with the content
				  requirements at
				  42 C.F.R. §
										438.416.
Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 3 - Member Grievances and Appeals, Provider Complaints, and State Fair Hearings in Soonerselect › Section 317:2-3-11 - Recordkeeping

Current through Vol. 41, No. 20, July 1, 2024
In compliance with
				  42 C.F.R. §
										438.3(h) and (u), the CE or
				  DBM will maintain records of each grievance and appeal for ten (10) years after
				  the later of the final date of the contract period or the date of completion of
				  any CE or DBM audit by the State, the Centers for Medicare and Medicaid
				  Services (CMS), the Office of the Inspector General, or the Comptroller
				  General. Such records will be part of OHCA's ongoing monitoring and will be
				  used to update and revise OHCA's SoonerSelect quality strategy. The record will
				  conform with the content requirements at
				  42 C.F.R. §
										438.416.