Or. Admin. Code § 411-045-0140

Current through Register Vol. 63, No. 12, December 1, 2024

Section 411-045-0140 - Administrative Hearings

(1) PACE participants are entitled to an administrative hearing by the Department regarding the action by the PACE program to deny services, payment of a claim, or to terminate, discontinue or reduce a course of treatment. PACE participants are also entitled to an administrative hearing for issues related to their eligibility for PACE benefits, or issues related to enrollment in a PACE program. Administrative hearings are governed by the following:

(a) A written hearing request must be received by the SPD/AAA PACE Liaison Case Manager no later than the 45th day following the date of the Notice of Action or written decision regarding an appeal;

(b) If the action involves a Notice of Action or decision concerning an appeal that involves continuation of services, and the PACE participant or PACE participant's representative wishes to have services continued while the hearing issue is being resolved, the PACE participant or PACE participant's representative must request a hearing before the effective date of the intended action or within 10 calendar days after the notice of action or written grievance decision was mailed or given to the PACE participant or PACE participant's representative.

(2) The SPD/AAA PACE Liaison Case Manager will review the administrative hearing requests, documentation related to the hearing issue, and computer records to determine whether the claimant or the person for whom the request is being made is or was a PACE participant at the time the action was taken, whether the hearing request was timely (requested within 45 calendar days of the Notice of Action, or the decision about a grievance) and whether continuation of benefits or services has been requested.

(3) The hearing request (DHS 443) must be referred to the Central Hearings Panel and a hearing officer requested. PACE administrative hearings are governed by OAR 461-025-0300 -0375 and the following, except to the extent that Department rules apply.

(4) A final order must be issued or the case otherwise resolved by the Department no later than 90 days following the Department's receipt of the request for hearing. Delay due to a postponement or continuance granted at the PACE participant or the PACE participant representative's request or with the consent of the PACE participant or the PACE participant's representative will not be counted in computing the time limit. The final order is the final decision of the Department.

(5) The PACE program will immediately transmit to the SPD/AAA PACE Liaison Case Manager any hearing request submitted on behalf of a participant.

(6) If an administrative hearing is requested by a PACE participant or the participant's representative, the PACE program will cooperate in the hearing process and will make available, as determined necessary by the Department, all persons with relevant information, including the staff person who attempted resolution of the grievance or appeal. The PACE program will also provide all pertinent files and clinical records, as well as the results of the review by the PACE program of the grievance or appeal in the hearing request and any attempts at resolution by the PACE program to the Department.

(7) If the PACE participant or his or her representative files a request for an administrative hearing, the SPD/AAA PACE Liaison Case Manager will immediately notify the PACE program. The PACE program will review the hearing request as a grievance or an appeal depending on the nature of the complaint. The SPD/AAA PACE Liaison Case Manager shall evaluate the request and, if warranted, request an informal meeting and will notify the other departments as appropriate.

(8) A PACE participant or his or her representative may request a delay in the administrative hearing in writing. This delay will not relieve the PACE program of resolving the grievance or appeal that was referred to them by the SPD/AAA PACE Liaison Case Manager within 30 days.

(9) PACE programs will review the hearing request, which has not been previously received or reviewed as a grievance or appeal, using the PACE program's grievance and appeals process as follows:

(a) The grievance or appeal will be reviewed immediately and will be resolved, if possible, within 30 days of receipt of the request for hearing in the Department;

(b) The PACE program's decision must be in writing and will be provided to the SPD/AAA PACE Liaison Case Manager, and to the PACE participant or his or her representative;

(c) If the grievance or appeal is not resolved within 30 days, or the participant or his or her representative does not accept resolution proposed by the PACE program on the hearing request, the PACE program will provide the SPD/AAA PACE Liaison Case Manager with all pertinent material and documentation within 30 days from the date of the transmittal of the request for hearing from the Department grievances and appeals are defined in OAR 410-141-0000, Definitions.

(10) If the PACE participant or his or her representative chooses to use the PACE program's grievance or appeal procedure as well as the administrative hearing process, the PACE program will ensure that the process is completed within 30 days of receipt, and the records sent to by the 30th day.

(11) If a PACE participant or the PACE participant's representative feels the participant's medical or dental problem cannot wait for the normal PACE program review process, including the PACE program's final resolution he or she may request an expedited hearing. The PACE program will inform PACE participants of the participants' rights to request an expedited hearing and provide participants with a copy of DHS Form 443 and Notice of Hearing Rights.

(12) Expedited hearings are requested using DHS Form 443.

(13) The PACE program will submit relevant documentation to DMAP's Medical Director within, as nearly as possible, 2 working days for a decision as to the necessity of an expedited administrative hearing. DMAP's Medical Director, in consultation with SPD's Medical Director, must decide within, as nearly as possible, 2 working days from date of request, if that PACE participant is entitled to an expedited hearing.

Or. Admin. Code § 411-045-0140

SDSD 5-2000, f. 12-29-00 cert. ef. 1-1-01; SPD 2-2005, f. & cert. ef. 1-4-05

Stat. Auth.: ORS 410.090

Stats. Implemented: ORS 410.070