State Fair Hearings.
(a) AHS shall alone be responsible for developing and implementing State Fair Hearing rules and policies.
(b) AHS shall be responsible for ensuring that State Fair Hearing rules, policies, and practices comply with the federal statutes and regulations, including provisions applicable to DVHA operations.
(c) In most cases, the beneficiaries must exhaust the internal appeal prior to making a State Fair Hearing request, unless exhaustion is deemed as set forth above in Section 2.18(b)(iii). A beneficiary who seeks review of a service not subject to the internal appeal process pursuant to HCAE 8.100.1 does not have to exhaust the internal appeal process.
(d) Beneficiaries have the right to file requests for a State Fair Hearing related to eligibility and premium determinations. With the written consent of the beneficiary, a provider or an authorized representative may request a State Fair Hearing on behalf of the beneficiary. The beneficiary, his/her representative, or the representative of a deceased beneficiary’s estate shall be parties to a State Fair Hearing.
(e) AHS shall retain responsibility for representing the State in any fair hearings pertaining to such eligibility and premium determinations. Hearing descriptions must be included in beneficiary and provider information within the contract.
(f) AHS will accept a timely request for a State Fair Hearing from a beneficiary and will process the request without delay. A timely request for a State fair hearing means that a beneficiary has requested the State Fair Hearing: within 120 days of the date the notice of resolution of the internal appeal was mailed to the beneficiary by DVHA (mailing is the postmark date which is considered one business day after the date of the notice), or, if there was no internal appeal (for those services for which the internal appeal process does not apply), then within 120 days after the mailing of the notice of adverse benefit determination. DocuSign Envelope ID: F73EF454-508D-44AC-ABD8-2A528194331A
(g) Beneficiaries also have the right to file a request for an expedited State Fair Hearing after exhausting the internal appeal process for expedited appeals, unless exhaustion is deemed as set forth above in Section 2.18(b)(iii).
(h) Expedited State Fair Hearing shall be resolved as expeditiously as the beneficiary’s health condition requires, but no later than 3 working days after the agency (the Human Services Board) received the case record and information for an appeal t...
State Fair Hearings. 1. To advise Enrollees that they may request a State fair hearing within 120 days of an MCO appeal resolution using the process specified in COMAR 10.01.04.
2. To be a party to any State fair hearing before the Office of Administrative Hearings held as a result of an enrollee’s appeal, along with the Enrollee, the Enrollee’s representative (if applicable), or the personal representative of a deceased Enrollee’s estate (if applicable).
3. To provide documentation regarding medical determinations to Enrollees and the Office of Administrative Hearings as required by COMAR 10.01.04 and other applicable law.
4. To continue the Enrollee’s benefits pending the outcome of the State fair hearing if all of the following occur:
a. The Enrollee files for continuation of benefits within 10 days of the MCO upholding its action;
b. The State fair hearing request is filed timely, meaning on or before the later of the following:
a. Within 10 days of the date on the MCO’s notice of appeal resolution; or
b. The intended effective date of the MCO's proposed action;
c. The State fair hearing involves the termination, suspension, or reduction of a previously authorized service; and
d. The services were ordered by an authorized provider.
5. To continue or reinstate the Enrollee's benefits while the State fair hearing is pending until one of the following occurs:
a. The Enrollee withdraws the State fair hearing; or
b. A State fair hearing decision adverse to the Enrollee is issued by the Office of Administrative Hearings.
State Fair Hearings. 13.1.4.1 The Contractor shall participate in State Fair Hearings as directed by EOHHS. Hearing shall be conducted in accordance with guidelines, rules, and regulations established by the State’s Administrative Procedures act and 42 C.F.R. Subpart E – Fair Hearings for Applicants and Beneficiaries.
13.1.4.2 The Contractor shall attend and prepare documentation for State Fair Hearings and related meetings.
State Fair Hearings