956 CMR, § 13.07 - Reconsideration Procedures
(1)
Scope of Reconsideration. The Connector will not
consider any claim or issue raised in the request for reconsideration that
could have been raised in the ongoing discrepancy resolution process, but that
was not.
(2)
Burden of
Proof. The burden of proving a ground for reconsideration will be
on the Carrier seeking reconsideration.
(3)
First-level
Review. The Connector will review the request for reconsideration.
In conducting this review, the Connector will consider the Final Risk
Adjustment Payments and Charges Report, along with all the data, calculations,
and other evidence supporting that report. Additionally, the Connector will
consider any documentary evidence included by the Carrier in its request for
reconsideration. The Connector may consider other evidence that it considers to
be relevant, provided that it will provide such evidence to the Carrier with a
reasonable opportunity to review and comment on such evidence. The Connector
may conduct this first-level review based solely on documentary evidence. The
Connector will inform the Carrier of its reconsideration decision in
writing.
(4)
Request
for Hearing. A Carrier that is aggrieved by the Connector's
decision after the first-level review may file a request for hearing. The
request must be in writing and must be submitted within ten calendar days after
issuance of the first-level reconsideration decision.
(5)
Hearing. The
hearing will be conducted using the policies and procedures set forth for
informal hearings pursuant to
801 CMR
1.02: Informal Fair Hearing Rules
or in any administrative bulletins issued by the Connector.
(6)
Conduct of
Hearing. The hearing officer will not consider any issue or claim
that was not raised in the request for reconsideration. The hearing officer
will not accept any evidence that was not presented by the Carrier with the
reconsideration request or considered by the Connector in the first-level
review.
(7)
Decision. The hearing officer will issue a final
decision in writing. The decision of the hearing officer will be the final
decision of the Connector.
(8)
Adjustment. In the event the final decision would
cause a change in the relative risk adjustment payment and transfers among
Carriers that would have been made in a Benefit Year, the Connector will
determine the level of adjustment required to be applied to each Carrier's
transfer amounts, with the adjustment made to the next risk adjustment transfer
after the issuance of the final decision and the conclusion of any proceedings
for judicial review arising from that decision.
Notes
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