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 317:2-3-12 - State fair hearing for members

Current through Vol. 41, No. 20, July 1, 2024
(a)
Right to
				state fair hearing.
With regard to grievances or appeals first filed
				with the CE and DBM, a member may request a state fair hearing under
				42 C.F.R.
				431 Subpart E only after receiving notice
				from the CE and DBM upholding an adverse benefit determination. The member will
				have one-hundred twenty (120) days from the date of the adverse benefit
				determination notice to request a state fair hearing. Refer to
				42 C.F.R. §§
										438.402(c)(1)(i) and
				438.408(f)(1).
(b)
CE or DBM policies and
				procedures.
The CE and DBM will implement established policies and
				procedures that allow a member described in (a) to initiate a state fair
				hearing process after having exhausted the CE or DBM's appeals process or after
				the member is deemed to have exhausted the process due to the CE or DBM's
				failure to adhere to notice and timing requirements.
(c)
Member's request for a state fair
				hearing.
The CE and DBM will allow the member to request a state fair
				hearing either through an established CE and DBM process or through an
				established OHCA process. Any CE and DBM process will ensure that notice of the
				request for state fair hearing is communicated in writing to the OHCA
				contracting officer within twenty-four (24) clock-hours of receiving the
				request.
(d)
CE or DBM
				documentation obligation.
The CE and DBM will provide documentation to
				the member, the member's authorized representative, OHCA, and the Office of
				Administrative Hearings.
(1)
Timing.
The CE and DBM will provide the support documentation
				(summary) described in this subsection within fifteen (15) calendar days after
				notification of the request for state fair hearing.
(2)
Information.
Support
				documentation (summary) will include, at minimum, the following information:
(A) The name and address of the member and,
				if applicable, the member's authorized representative;
(B) A summary statement concerning why the
				member has filed a request for state fair hearing;
(C) A brief chronological summary of the CE
				or DBM's action in relationship to the matter underlying the member's request
				for state fair hearing;
(D) The
				member's appeal request, along with any supporting documentation, if received
				by the CE and DBM;
(E) Any
				applicable correspondence between the CE and DBM and the member, including
				system notes entered by one (1) or more CE and DBM employees based on one (1)
				or more telephone conversations with the member;
(F) All exhibits offered at any hearing held
				with the CE and DBM;
(G) All
				documents the CE and DBM used to reach its decision;
(H) A statement of the legal basis for the CE
				or DBM's decision;
(I) A citation
				of the applicable policies and/or legal authorities relied upon by the CE or
				DBM in making its decision;
(J) A
				copy of the notice which notified the member of the decision in question;
(K) The names and titles of any CE
				or DBM employees who will serve as witnesses at the state fair hearing; and
(L) Any other information
				requested by the member, the member's authorized representative, OHCA, or the
				Office of Administrative Hearings when the information relates to the state
				fair hearing or any matter giving rise to the state fair hearing.