N.Y. Comp. Codes R. & Regs. tit. 9 § 9720.2

Current through Register Vol. 46, No. 50, December 11, 2024

Section 9720.2 - Right to a fair hearing

(a) Applicants and participants shall be entitled to a fair hearing to have a contractor's determination after reconsideration reviewed on the following grounds:

(1) denial of benefits;

(2) failure to determine the applicant's eligibility or, if found eligible, failure to issue a card or authorize services within three days from the date the applicant met his/her registration fee, premium or deductible requirement;

(3) discontinuance or suspension of coverage, in whole or in part;

(4) computation of his/her cost-sharing responsibilities;

(5) any other grounds affecting the applicant or participant's coverage, including a determination of the receipt of medical assistance or equivalent or better public or private insurance benefits.

(b) Notwithstanding the above, participants have no right to a hearing when the contractor discontinues payment to a provider or the panel authorizes a mass change.

N.Y. Comp. Codes R. & Regs. Tit. 9 § 9720.2