Okla. Admin. Code § 317:2-1-2 - [Effective9/14/2022]Appeals
(a)
Request
for appeals.
(1) For the purpose of
calculating the timeframe for requesting an administrative appeal of an agency
action, the date on the written notice shall not be included. The last day of
the timeframe shall be included, unless it is a legal holiday as defined by
Title 25 of the Oklahoma Statutes (O.S.) Section (§) 82.1, or any other
day the Oklahoma Health Care Authority (OHCA) is closed or closes early, in
which case, the timeframe runs until the close of the next full business day.
(2) An appeals request that an
aggrieved member or provider sends via mail is deemed filed on the date that
the agency receives it.
(b)
Member process overview.
(1) The appeals process allows a member to
appeal a decision relating to program benefits. Examples are decisions
involving medical services, prior authorizations for medical services, or
discrimination complaints.
(2) In
order to initiate an appeal, the member must file a LD-1 (Member
Complaint/Grievance Form) within thirty (30) calendar days of the date the OHCA
sends written notice of its action, in accordance with Oklahoma Administrative
Code (OAC) 317:2-1-2(a), above, or, in matters in which a formal notice is not
sent by the agency, within thirty (30) days of the date on which the member
knew or should have known the facts or circumstances serving as the basis for
appeal.
(3) If the LD-1 form is not
received timely, the administrative law judge (ALJ) will cause to be issued a
letter stating the appeal will not be heard. In the case of tax warrant
intercept appeals, if the LD-1 form is not received by OHCA within the
timeframe pursuant to 68 O.S. § 205.2, OHCA similarly will cause to be
issued a letter stating the appeal will not be heard because it is untimely.
(4) If the LD-1 form is not
completely filled out or if necessary documentation is not included, then the
appeal will not be heard.
(5) OHCA
will advise members that if assistance is needed in reading or completing the
grievance form, arrangements will be made to provide such assistance.
(6) Upon receipt of the member's
appeal, a fair hearing before the ALJ will be scheduled. The member will be
notified in writing of the date and time of the hearing. The member must appear
at the hearing, either in person or telephonically. Requests for a telephone
hearing must be received in writing on OHCA's LD-4 (Request for Telephonic
Hearing) form no later than ten (10) calendar days prior to the scheduled
hearing date. Telephonic hearing requests will only be granted by the OHCA's
chief executive officer (CEO) or his/her designee, at his/her sole discretion,
for good cause shown, including, for example, the member's physical condition,
travel distances, or other limitations that either preclude an in-person
appearance or would impose a substantial hardship on the member.
(7) The hearing shall be conducted according
to OAC
317:2-1-5. The
ALJ's decision may be appealed to the CEO of the OHCA, which is a record review
at which the parties do not appear (OAC
317:2-1-13)
.
(8) Member appeals are ordinarily
decided within ninety (90) days from the date on which the member's timely
request for a fair hearing is received, unless:
(A) The appellant was granted an expedited
appeal pursuant to OAC
317:2-1-2.5;
(B) The OHCA cannot reach a
decision because the appellant requests a delay or fails to take a required
action, as reflected in the record;
(C) There is an administrative or other
emergency beyond OHCA's control, as reflected in the record; or
(D) The appellant filed a request for an
appeal of a denied step therapy exception request, pursuant to OAC 317:2-1-18.
(9) Tax warrant
intercept appeals will be heard directly by the ALJ. A decision is normally
rendered by the ALJ within twenty (20) days of the hearing before the ALJ.
(c)
Provider
process overview.
(1) The proceedings
as described in this subsection contain the hearing process for those appeals
filed by providers. These appeals encompass all subject matter cases contained
in OAC 317:2-1-2(d)(2).
(2) All
provider appeals are initially heard by the OHCA ALJ under OAC 317:2-1-2(d)(2).
(A) In order to initiate an appeal, a
provider must file the appropriate LD form within thirty (30) calendar days of
the date the OHCA sends written notice of its action, in accordance with OAC
317:2-1-2(a), above. LD-2 forms should be used for Program Integrity audit
appeals; LD-3 forms are to be used for all other provider appeals.
(B) Except for OHCA Program Integrity audit
appeals, if the appropriate LD form is not received timely, the ALJ will cause
a letter to be issued stating that the appeal will not be heard.
(C) A decision ordinarily will be issued by
the ALJ within forty-five (45) days of the close of all evidence in the appeal.
(D) Unless otherwise limited by
OAC
317:2-1-7
or
317:2-1-13,
the ALJ's decision is appealable to OHCA's CEO.
(d)
ALJ jurisdiction. The ALJ
has jurisdiction of the following matters:
(1)
Member appeals.
(A) Discrimination complaints regarding the
SoonerCare program;
(B) Appeals
which relate to the scope of services, covered services, complaints regarding
service or care, enrollment, disenrollment, and reenrollment in the SoonerCare
Program;
(C) Fee-for-service
appeals regarding the furnishing of services, including prior authorizations;
(D) Appeals which relate to the
tax warrant intercept system through the OHCA. Tax warrant intercept appeals
will be heard directly by the ALJ. A decision will be rendered by the ALJ
within twenty (20) days of the hearing;
(E) Proposed administrative sanction appeals
pursuant to OAC
317:35-13-7.
Proposed administrative sanction appeals will be heard directly by the ALJ. A
decision by the ALJ will ordinarily be rendered within twenty (20) days of the
hearing before the ALJ. This is the final and only appeals process for proposed
administrative sanctions;
(F)
Appeals which relate to eligibility determinations made by OHCA;
(G) Appeals of insureds participating in
Insure Oklahoma which are authorized by OAC
317:45-9-8; and
(H) Appeals which relate to a
requested step therapy protocol exception as provided by 63 O.S. § 7310.
(2)
Provider
appeals.
(A) Whether Pre-admission
Screening and Resident Review (PASRR) was completed as required by law;
(B) Denial of request to disenroll
member from provider's SoonerCare Choice panel;
(C) Appeals by long-term care facilities for
administrative penalty determinations as a result of findings made under OAC
317:30-5-131.2(b)(5)(B)
and (d)(8);
(D) Appeals of Professional Service Contract
awards and other matters related to the Central Purchasing Act pursuant to
Title 74 O.S. §
85.1 et
seq.;
(E) Drug rebate appeals;
(F) Provider appeals of OHCA
Program Integrity audit findings pursuant to OAC
317:2-1-7.
This is the final and only appeals process for appeals of OHCA Program
Integrity audit findings;
(G)
Oklahoma Electronic Health Records Incentive program appeals related only to
incentive payments, incentive payment amounts, provider eligibility
determinations, and demonstration of adopting, implementing, upgrading, and
meaningful use eligibility for incentives;
(H) Supplemental Hospital Offset Payment
Program (SHOPP) annual assessment, supplemental payment, fees or penalties as
specifically provided in OAC
317:2-1-15;and
(I) Appeals from any adjustment
made to a long-term care facility's cost report pursuant to OAC
317:30-5-132,
including any appeal following a request for reconsideration made pursuant to
OAC
317:30-5-132.1.
Notes
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