Section He-W 512.07 - Appeals Process for the Premium Assistance Program(a) The appeals process for the PAP shall address PAP participants' requests for the appeal of any adverse decisions made by the QHP related to a PAP participant's QHP covered benefits and decisions made by the department related to eligibility or wrap benefits related to the PAP.(b) PAP participants who want to appeal a decision made by the QHP regarding a QHP's covered benefits shall exhaust all private market appeals processes applicable under RSA 420-J:5 and RSA 420-J:5-a through 5-e prior to requesting a state fair hearing with the department. The private market appeals processes include internal review conducted by the QHP under RSA 420-J:5 with respect to both medical necessity and coverage issues, and an independent external review conducted by an independent review organization (IRO) under RSA 420-J:5-a through 5-e with respect to medical necessity issues only.(c) PAP participants shall have the right to a state fair hearing in accordance with (d) and (e) below when the enrollee has exhausted the private market appeals processes without having the issue under appeal resolved in his or her favor. PAP enrollees shall file a request for a fair hearing in accordance with He-C 200.(d) PAP participants shall have the right to a state fair hearing for the following issues: (1) For medical necessity issues, at the conclusion of the external review process as provided in RSA 420-J:5-a-5-e;(2) For issues not related to medical necessity, at the conclusion of a QHP internal review process as provided in RSA 420-J:5; and(3) For decisions related to eligibility for medicaid or decisions made regarding wrap benefits made by the department, without first exhausting any private market appeals processes.(e) Requests for a department fair hearing shall be made in writing within 30 calendar days of the date of the notice of the resolution of the appeal through the private market appeals process.(f) A PAP participant's benefits shall be continued during a department fair hearing if: (1) The individual requests a department fair hearing within 10 calendar days of the notice of the disposition of the private market appeals process or the notice of the department's decision on eligibility or wrap benefits;(2) The individual requests continuation of benefits; and(3) The individual identifies a medicaid enrolled provider to provide the benefit requested.(g) If the QHP's adverse decision is upheld in a department fair hearing, the member shall be liable for the cost of continued benefits.N.H. Admin. Code § He-W 512.07
Amended by Volume XXXVI Number 01, Filed January 7, 2016, Proposed by #11012, Effective 1/1/2016, Expires 6/29/2016.Amended by Volume XXXVI Number 28, Filed July 14, 2016, Proposed by #11119, Effective 6/29/2016, Expires 6/29/2026.