Section He-W 506.09 - Department Fair Hearing Process(a) A member shall exhaust the MCO or DO appeal process prior to filing a request for a fair hearing with the department, subject to the following: (1) Grievances shall not be the subject of a department fair hearing; and(2) The MCO or DO shall have resolved an appeal under He-W 506.08 and provided notice of that resolution prior to the member requesting a fair hearing with the department, except that a member shall be deemed to have exhausted the MCO's or DO's appeal process if the MCO or DO fails to adhere to the notice and timing for expedited and standard appeals as described in He-W 506.08(f), (h), and (j).(b) If the member does not agree with the MCO's or DO's resolution of an appeal, the member may file a request, in accordance with He-C 200, for a department fair hearing.(c) Requests for a department fair hearing shall be made in writing within 120 calendar days of the date of the MCO's or DO's notice of the resolution of the appeal.(d) A member in (b) above may request an expedited resolution of a department fair hearing if the department determines that the time otherwise permitted for a hearing could seriously jeopardize the member's life, physical or mental health, or ability to attain, maintain, or regain maximum function, and: (1) The MCO or DO adversely resolved the member's appeal, wholly or partially; or(2) The MCO or DO failed to resolve the appeal within 72 hours and failed to extend the 72-hour deadline in accordance with 42 CFR 438.408(c) and He-W 506.08(i).(e) The department shall notify the member as expeditiously as possible as to whether the request for an expedited department fair hearing is granted or denied. If oral notice is provided, the department shall follow up with written notice, which might be made through electronic means.(f) If the department denies the member's request for an expedited department fair hearing, the department shall schedule a department fair hearing within 90 days from the date the member filed an MCO or DO appeal not including the number of days the member took to subsequently file for a department fair hearing.(g) If the department grants the member's request for an expedited department fair hearing, then the department shall resolve the appeal within 3 business days after the department receives from the MCO or DO the case file and any other necessary information. The MCO or DO shall have no more than 3 days from the date the department notifies the MCO or DO that it has granted the member's expedited appeal, to provide the case file to the department.(h) A member's benefits shall be continued during a department fair hearing if: (1) The member received benefits pending the MCO or DO appeal; and(2) The member requests a department fair hearing and continuation of benefits within 10 calendar days of the date the MCO or DO sends the notice of adverse decision of an MCO or DO appeal to the member.(i) If the member did not receive benefits pending the MCO or DO appeal, then a member's benefits shall be continued during a department fair hearing if:(1) The member requests a department fair hearing within 10 calendar days of the date the MCO or DO mails the notice of decision adverse to the member;(2) The member requests continuation of benefits pending the department fair hearing;(3) The department fair hearing involves the termination, suspension, or reduction of a previously authorized service;(4) The service was ordered by an authorized provider; and(5) The original authorization period for the service has not expired.(j) Only the member, the member's authorized representative, or the member's legal guardian may request benefits pending a department fair hearing of a MCO or DO decision.(k) Providers acting as an authorized representative shall not request continuation of benefits pending the appeal even with written consent.(l) If the MCO's or DO's adverse decision is upheld in a department fair hearing, the MCO or DO may institute recovery procedures against the member to recoup the cost of any continued benefits furnished to the member.N.H. Admin. Code § He-W 506.09
Amended by Volume XXXVIII Number 23, Filed June 7, 2018, Proposed by #12537, Effective 5/24/2018, Expires 5/24/2028.Amended by Volume XLII Number 45, Filed November 10, 2022, Proposed by #13474, Effective 10/25/2022, Expires 10/25/2032.Amended by Number 28, Filed July 13, 2023, Proposed by #13670, Effective 6/22/2023, Expires 6/22/2033.