Cal. Code Regs. Tit. 10, § 6542 - General Eligibility Appeals Requirements for SHOP
(a) An
employer shall have the right to appeal:
(1)
An eligibility determination made by the SHOP in accordance with this
Article;
(2) A failure by the SHOP
to provide a timely eligibility determination in accordance with this Article;
or
(3) A failure of the SHOP to
provide written notice to an employer of the SHOP's eligibility determination
as provided in Section
6524(c) within 15
calendar days of receiving a completed application from an employer.
(b) An employee shall have the
right to appeal:
(1) An eligibility
determination made by the SHOP in accordance with this Article;
(2) A failure by the SHOP to provide a timely
eligibility determination in accordance with this Article; or
(3) A failure of the SHOP to provide written
notice to an employee of the SHOP's eligibility determination as provided in
Section 6524(c) within 15
calendar days of receiving a completed application from an employee.
(c) Notices of the right to appeal
an eligibility determination pursuant to Section
6524(c) and (d)
shall include:
(1) The reason for the
eligibility determination, including a citation to the applicable regulations;
and
(2) The procedure by which the
employer or employee may request an appeal of the eligibility
determination.
(d) The
SHOP and appeals entity shall:
(1) Allow an
employer or employee to request an appeal within 90 days of the date of the
notice of the eligibility determination, unless the appeals entity determines
that good cause exists for allowing a late appeal request.
(2) Accept appeal requests submitted in
person or through an appeals representative, via telephone, facsimile, mail,
electronic mail or, as soon as it becomes available, the SHOP's Internet Web
Site;
(3) Comply with the
accessibility requirements specified in
45 CFR
155.205(c);
(4) Assist the employer or employee with the
submission and processing of the appeal request, if requested, and not limit or
interfere with the employer's or employee's right to request an appeal;
and
(5) Consider an appeal request
valid if it is submitted in accordance with the requirements of this
section.
(e) Upon
receipt of an appeal request pursuant to this section, the SHOP shall transmit
the appeal request to the appeals entity via secure electronic interface within
three (3) business days.
(1) The appeal
request, if the appeal was initially made to the SHOP; and
(2) All records concerning the eligibility of
the employer or employee who is appealing.
(f) The appeals entity shall confirm receipt
of the records transmitted pursuant to subdivision (e) of this section within
three (3) business days.
(g) The
appeals entity shall conduct all appeals on behalf of the SHOP pursuant to this
Article.
(h) For purposes of this
Article, an administrative law judge designated by the appeals entity shall
determine, on a case-by-case basis, the validity of all appeals requests and
all determinations of good cause.
(i) Upon receipt of a valid appeal request,
the appeals entity shall send written acknowledgment to the appellant, or the
employer and employee if the employee is the appellant, within five (5)
business days from the date on which the valid appeal request is received. The
written acknowledgment shall include:
(1) An
explanation of the appeals process;
(2) Instructions for submitting additional
evidence for consideration; and
(3)
Information regarding the appellant's opportunity for informal resolution prior
to the hearing pursuant to Section
6544.
(j) Upon receipt of an invalid appeal request
because it fails to meet the requirements of this section, the appeals entity
shall:
(1) Within five (5) business days from
the date on which the invalid appeal request is received, send written notice
to the appellant informing them:
(A) That the
appeal request has not been accepted;
(B) Of the nature of the defect in the appeal
request; and
(C) An explanation
that the appellant may cure the defect, if curable, and resubmit the appeal
request if it meets the timeliness requirements of subdivision (d)(1) of this
section, or if the timeliness requirement in subdivision (d)(1) has lapsed,
then within 10 calendar days from the date of the notice specified in
subdivision (j)(1) of this section.
(2) Treat as valid an amended appeal request
that meets the requirements of this section.
(k) The appellant has the right to be
represented by an appeals representative.
(l) An appellant may seek judicial review to
the extent it is available by law.
(m) The appeals entity shall ensure that all
data exchanges that are part of the appeals process, comply with the Federal
and State privacy and security standards specified in
45 CFR Section
155.260 and the Information Practices Act of
1977 (Cal. Civ. Code, §
1798 et seq.) and are in an
electronic format that is consistent with
45 CFR Section
155.270.
(n) Both the SHOP and the appeals entity
shall provide the appellant with the opportunity to review their entire
eligibility file, including all papers, requests, documents, and relevant
information in the SHOP's possession at any time from the date on which an
appeal request is filed to the date on which the appeal decision is
issued.
Notes
Note: Authority cited: Section 100504, Government Code. Reference: Section 100506, Government Code; and 45 CFR § 155.740.
Note: Authority cited: Section 100504, Government Code. Reference: Section 100506, Government Code; and 45 CFR § 155.740.
2. New section refiled 6-2-2014 as an emergency; operative 6-2-2014 (Register 2014, No. 23). A Certificate of Compliance must be transmitted to OAL by 9-2-2014 or emergency language will be repealed by operation of law on the following day.
3. New section refiled 9-2-2014 as an emergency pursuant to Government Code section 100504(a)(6), as modified by Senate Bill 857 (Stats.
4. Senate Bill 75 (Stats.
5. Certificate of Compliance as to 9-2-2014 order, including amendments, transmitted to OAL 5-4-2016 and filed 6-14-2016; amendments effective
6. Amendment of subsection (b)(2) filed 9-7-2021 as an emergency; operative
7. Certificate of Compliance as to 9-7-2021 order, including further amendment of subsections (j)(1) and (n), transmitted to OAL 8-22-2024 and filed 9-23-2024; amendments effective
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