Ohio Admin. Code 3701-43-23 - Appeal procedures for decisions concerning the program for medically handicapped children
(A) This rule prescribes the procedures for
appealing proposed decisions of the director concerning the program for
medically handicapped children that are subject to division (H) of section
3701.023 of the Revised Code.
These proposed decisions include:
(1) A
proposed determination under rules
3701-43-15 and
3701-43-11 of the Administrative
Code that an applicant or recipient , as defined in paragraphs (C) and (R) of
rule 3701-43-01 of the Administrative
Code, does not meet the requirements for financial or medical eligibility for
payment for treatment or diagnostic services prescribed by rules 3701-43-11,
3701-43-16, and
3701-43-17 of the Administrative
Code;
(2) A proposed determination
under rule
3701-43-15 of the Administrative
Code that an adult cystic fibrosis applicant or recipient , as defined in
paragraphs (A), (C), and (R) of rule
3701-43-01 of the Administrative
Code, does not meet the financial eligibility requirements under rule
3701-42-16
3701-43-16 of the Administrative Code or the medical
eligibility requirements for payment for treatment services under rule
3701-43-17 of the Administrative
Code;
(3) A proposed determination
under rule
3701-43-13 of the Administrative
Code that an applicant for or recipient of service coordination, as defined in
paragraph (S) of rule
3701-43-01 of the Administrative
Code, does not meet the requirements for eligibility for service
coordination;
(4) A proposed denial
of a request for authorization of provision of treatment services or goods
under rule
3701-43-18 of the Administrative
Code or provision of diagnostic services under rule
3701-43-12 of the Administrative
Code;
(5) A proposed termination of
approval under rule
3701-43-10 of the Administrative
Code of a provider , as defined in paragraph (P) of rule
3701-43-01 of the Administrative
Code; and
(6) A proposed decision
to pay an amount less than the charges for authorized goods or services under
rule 3701-43-09 of the Administrative
Code.
(B) An affected
party may request reconsideration of a proposal by the director to make one of
the decisions listed in paragraph (A) of this rule by filing a written request
for reconsideration with the director no later than forty-five days after the
date on the notice of the proposed action issued under the applicable provision
of this chapter of the Administrative Code. The request for reconsideration
shall contain a statement of the reasons that the affected party believes that
the proposed decision is incorrect or inappropriate, a copy of the denial
letter, and may also include any written documentation, arguments, or other
materials that the affected party wishes to submit for the purposes of this
rule:
(1) An item is filed with the director
when it is received by the Ohio department of health.
(2) "Affected party" means:
(a) The applicant or recipient , recipient 's
parent, guardian or other legal representative, in the case of the proposed
decisions listed in paragraphs (A)(1) to (A)(4) of this rule. The applicant ,
recipient , parent, guardian or other legal representative may be represented in
proceedings under this rule by any person whom the applicant , recipient ,
parent, guardian or other legal representative has authorized in writing to
represent the interests of the applicant , recipient , parent, guardian or other
legal representative relative to the director 's proposed decision.
(b) The provider , in the case of a proposed
decision listed in paragraph (A)(5) of this rule.
(c) The provider who submitted the request
for payment, in the case of a proposed decision listed in paragraph (A)(6) of
this rule.
(C) For the purposes of reconsideration, the
director may request from the affected party additional, relevant records or
documentation within forty-five days of receipt of the request for
reconsideration or additional information previously submitted under this
paragraph. The affected party shall file any requested information with the
director no later than forty-five days after the date on the request for
additional information.
(D) Within
forty-five days after receipt of a request for reconsideration from an affected
party that complies with paragraph (B) of this rule and of all necessary
additional information filed in accordance with paragraph (C) of this rule, the
director shall issue written notification to the affected party who requested
the reconsideration:
(1) That a decision has
been rendered in favor of the affected party; or
(2) That the proposal to issue a decision
adverse to the affected party remains in effect and that the affected party may
request an adjudicatory hearing concerning the proposed decision. The notice of
the opportunity for a hearing shall include a statement of the reasons for the
proposed decision, citations of the statutes or rules directly involved and a
description of the method for requesting a hearing, in accordance with
paragraph (E) of this rule.
(E) Following receipt of the notice required
under paragraph (D) of this rule, an affected party may request an adjudication
hearing concerning a proposed decision listed in paragraph (A) of this rule by
filing a written hearing request with the director no later than thirty days
after the date of mailing of the notice provided for by paragraph (D) of this
rule. If the hearing is requested timely, it shall be conducted and an
adjudication order shall be issued. Upon receipt of a timely filed request for
a hearing, the hearing shall be scheduled for a date not later than
seventy-five days from the date the written request is received by the
director . The director shall notify the affected party of the date, time, and
location of the hearing no less than seven days before the date set for the
hearing. The hearing may be continued at the request of any party with the
approval of the director or upon his own motion.
(F) The director shall appoint a hearing
officer to preside over the hearing. At the hearing, the rules of evidence
shall be liberally construed. A stenographic record may be made upon the
request of any party at the expense of the party requesting the
record.
(G) The affected party may
appear in person at the hearing and may have in attendance legal counsel or
such other representative of the affected party's choice and at the affected
party's expense. The affected party may present testimony and/or evidence and
may question witnesses present at the hearing. In lieu of appearing at the
hearing, the affected party may submit written materials to be examined by the
hearing officer.
(H) The hearing
officer shall submit to the director within thirty days of the date of the
conclusion of the hearing a written report setting forth his findings of fact
and conclusions of law and a recommendation of the action to be taken. The
director shall send by certified mail a copy of the hearing officer's report
and recommendation to the affected party within seven days of receipt of the
written report. The affected party or the department may file within ten days
of receipt of the written report objections to the report, which shall be
considered by the director before approving, modifying, or disapproving the
recommendation.
(I) The director
shall issue an order to approve, modify, or disapprove the report and
recommendation of the hearing officer and shall send notice of his action by
certified mail to the affected party. The decision of the director under this
paragraph shall be final.
Notes
Promulgated Under: 119.03
Statutory Authority: 3701.021
Rule Amplifies: 3701.021, 3701.022, 3701.023
Prior Effective Dates: 1/2/1989, 5/28/93, 7/12/93, 12/1/01, 2/13/12
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.