Section 2699.6612 - Appeals(a) The following program decisions may be appealed to the board: (1) A decision that an individual is not qualified to participate or continue to participate in the program.(2) A decision that an individual is not eligible for enrollment or continuing enrollment in the program.(3) A decision as to the effective date of coverage.(b) An appeal shall be filed in writing with the program within sixty (60) calendar days of the date of the notice of the decision being appealed.(c) Appeals shall be reviewed pursuant to the following process: (1) First level appeals shall be filed with the program, and the program shall make a determination on the appeal within thirty (30) calendar days from the receipt of the appeal. The program shall notify the appellant in writing of the programs decision and that he or she may request a second level review by the Executive Director.(2) Second level appeals shall be filed with the Executive Director within thirty (30) calendar days of the date of the notice of the determination concerning the first level appeal. The program may contact the appellant to get clarification and additional information to make a determination. The program shall notify the appellant in writing of the Executive Director's decision and that he or she may request an administrative hearing.(3) As determined by the program, an administrative hearing shall be conducted by an Administrative Law Judge employed by the Office of Administrative Hearings pursuant to the provisions of Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code, or pursuant to the pre- and post-hearing procedures set forth in Article 3 (commencing with Section 1140) of Chapter 2 of Division 2 of Title 1 of the California Code of Regulations as modified by Section 12693.89 of the Insurance Code. Requests for administrative hearings shall be filed with the program within thirty (30) calendar days of receipt of the determination concerning the second level appeal.(d) An appeal shall include all of the following:(1) A copy of any decision being appealed, or a written statement of the action or failure to act being appealed.(2) A statement describing the issues that are being disputed.(3) A statement describing the program statute, regulation, or other written representation of program policy that the program or board violated.(4) A statement of the resolution being requested.(5) Any other relevant information.(e) An appellant may request continued enrollment while the appeal is being determined. The enrollment shall continue until a determination is made. Family contributions and copays are required during the continued enrollment period. An appeal that requests continued enrollment shall: (1) Be limited to appeals filed pursuant to subsection (c)(1) of this section.(2) Be filed in writing with the program within fifteen (15) calendar days of the date the notice of the decision being appealed.(3) Meet all other requirements described in this section.Cal. Code Regs. Tit. 10, § 2699.6612
1. New section filed 7-31-2003 as an emergency; operative 7-31-2003 (Register 2003, No. 31). A Certificate of Compliance must be transmitted to OAL by 1-27-2004 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 7-31-2003 order transmitted to OAL 11-17-2003 and filed 12-30-2003 (Register 2004, No. 1). Note: Authority cited: Sections 12693.21 and 12693.41, Insurance Code. Reference: Sections 12693.85, 12693.86, 12693.87 and 12693.89, Insurance Code; and 42 CFR Section 457.1170.
1. New section filed 7-31-2003 as an emergency; operative 7-31-2003 (Register 2003, No. 31). A Certificate of Compliance must be transmitted to OAL by 1-27-2004 or emergency language will be repealed by operation of law on the following day.
2. Certificate of Compliance as to 7-31-2003 order transmitted to OAL 11-17-2003 and filed 12-30-2003 (Register 2004, No. 1).