Utah Admin. Code R410-14-3 - Administrative Adjudicative Procedures

(1) Except as provided in this rule or as otherwise designated by rule or statute or converted pursuant to Subsection 63G-4-202(3), all adjudicative proceedings conducted pursuant to this rule are informal proceedings.

(2) An aggrieved person may file a written request for agency action pursuant to Section 63G-4-201, and in accordance with this rule.

(a) A provider may file a written request for agency action without the consent of the member or MCO enrollee if the request for agency action pertains to the denial of an authorization for service or a denial of payment on a claim.

(b) A provider may not file a request for agency action if the request for agency action pertains to the denial, change, or termination of eligibility of a member or enrollee for a medical assistance program.

(3) If a medical issue is in dispute, each request must include supporting medical documentation. DIH may schedule a hearing only when it receives sufficient medical records and may dismiss a request for agency action if it does not receive supporting medical documentation in a timely manner.

(4) An agency shall provide a written notice of action to each aggrieved person. These actions include:

(a) eligibility for assistance;

(b) scope of service;

(c) denial or limited prior authorization of a requested service including the type or level of service; and

(d) payment of a claim.

(5) The notice must include:

(a) a statement of the action the agency intends to take;

(b) the date the intended action becomes effective;

(c) the reasons for the intended action;

(d) the specific regulations that support the action, or the change in federal law, state law or DIH policy which requires the action;

(e) the right to request a hearing;

(f) the right to represent oneself, the right to legal counsel, or the right to use another representative at the hearing; and

(g) if applicable, an explanation of the circumstances under which reimbursement for medical services will continue or may be reinstated pursuant to this rule.

(6) The agency shall mail the notice at least ten calendar days before the date of the intended action except:

(a) the agency may mail the notice before the date of action in accordance with 42 CFR 431.213;

(b) the agency may shorten the period of advance notice to five days before the date of action if it has facts that indicate it must take action due to probable fraud by the member or provider and the facts have been verified by affidavit.

Notes

Utah Admin. Code R410-14-3

Amended by Utah State Bulletin Number 2016-5, effective 2/10/2016 Amended by Utah State Bulletin Number 2018-12, effective 5/29/2018 Amended by Utah State Bulletin Number 2023-08, effective 3/30/2023