Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 2 - Grievance Procedures and Process › Subchapter 1 - Administrative Appeals › Section 317:2-1-11 - Medicaid Drug Utilization Review Board (DUR) appeal process

Current through Vol. 41, No. 20, July 1, 2024
This Section explains the appeal process, pursuant to Title
				  63 Oklahoma Statutes (O.S.) §
									5030.3(B),
				  accorded any party aggrieved by a decision of the Oklahoma Health Care
				  Authority (OHCA) Board or Chief Executive Officer (CEO) concerning a proposed
				  recommendation of the Medicaid Drug Utilization Review Board (DUR).
(1) The aggrieved party may appeal pursuant
				to Oklahoma Administrative Code (OAC)
				317:2-1-2 et seq. (OHCA
				Appeals).
(2) The Board finds that
				the prescription of Title 63 O.S. §
									5030.3(B)
				is somewhat contradictory with the functions of the DUR Board. More
				specifically, in most instances, the DUR Board suggests policies that must be
				rule made. Rules promulgated by the OHCA Board do not lend to an "individual
				proceeding notice" as contemplated by Article II of the Oklahoma Administrative
				Procedures Act, specifically, Title 75 O.S. §
									309.
				Thus, in instances where the OHCA Board promulgates rules as a result of policy
				recommendations by the DUR Board, this Board will consider a party aggrieved by
				these rules to have filed a Petition for Rulemaking under 75 O.S. § 305.
				In making this interpretation of 63 O.S. § 5030, the Board will not
				enforce the last sentence of 75 O.S. § 305. In making this interpretation,
				the Board finds that it is taking two somewhat conflicting provisions, and
				combining them to effectuate the intent of the legislature - to provide a
				hearing to those aggrieved by recommendations by the DUR Board and accepted by
				the OHCA Board.
(3) In instances
				where the DUR Board makes a recommendation accepted by the Board against an
				individual provider [for example, a recommendation under
				42 United States Code
				1396r-8(g)(3)(C)(iii)(IV) ],
				OHCA will provide an individual proceeding under the Oklahoma Administrative
				Procedures Act.
(4) In any appeal
				under (1) and (2) of this subsection, the OHCA Board delegates the OHCA ALJ to
				preside over the above hearing and present the Board with proposed findings of
				fact and conclusions of law in accordance with Article II of the Administrative
				Procedures Act. The OHCA Board may accept the ALJ's written decision, reject
				it, or amend the recommendations.
(5) Appeals filed pursuant to (1) and (2) of
				this subsection, will be made within thirty (30) days of the OHCA Board's
				acceptance of the recommendation by the DUR Board.
(6) After Proposed Findings of Fact and
				Conclusions of Law are presented to the OHCA Board, the Board will have a
				period of 120 days to issue a final administrative order.
(7) The Agency's Legal Services Division will
				construct a form called the LD-3, which will be used for parties to file an
				action under (1) and (2) of this subsection.
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