(a) Member Process Overview.

• (1) The appeals process allows a member to appeal a decision which adversely affects their rights.  Examples are decisions involving medical services, prior authorizations for medical services, or discrimination complaints.
• (2) In order to file an appeal, the member files a LD-1 form within 20 days of the triggering event.  The triggering event occurs at the time when the Appellant (Appellant is the person who files a grievance) knew or should have known of such condition or circumstance for appeal.
• (3) If the LD-1 form is not received within 20 days of the triggering event, OHCA sends the Appellant a letter stating the appeal will not be heard because it is untimely.  In the case of tax warrant intercept appeals, if the LD-1 form is not received within 30 days of written notice sent by OHCA according to Title 68 Okla. Stat. ' 205.2, OHCA sends the Appellant a letter stating the appeal will not be heard because it is untimely.
• (4) If the LD-1 form is not completely filled out and necessary documentation not included, then the appeal will not be heard.
• (5) The staff advises the Appellant that if there is a need for assistance in reading or completing the grievance form that arrangements will be made.
• (6) Upon receipt of the member's appeal, a fair hearing before the Administrative Law Judge (ALJ) will be scheduled.  The member will be notified in writing of the date and time for this procedure.  The member must appear at this hearing and it is conducted according to 317:2-1-5. The ALJ's decision may be appealed to the Chief Executive Officer of the OHCA, which is a record review at which the parties do not appear (317:2-1-13).
• (7) Member appeals are ordinarily decided within 90 days from the date OHCA receives the member's timely request for a fair hearing unless the member waives this requirement. [Title 42 C.F.R. Section 431.244(f)]
• (8) Tax warrant intercept appeals will be heard directly by the ALJ. A decision is normally rendered by the ALJ within 20 days of the hearing before the ALJ.

(b) Provider Process Overview.

• (1) The proceedings as described in this Section contain the hearing process for those appeals filed by providers.  These appeals encompass all subject matter cases contained in 317:2-1-2(c)(2).
• (2) All provider appeals are initially heard by the OHCA Administrative Law Judge under 317:2-1-2(c)(2).
  • (A) The Appellant (Appellant is the provider who files a grievance) files an LD form requesting a grievance hearing within 20 days of the triggering event. The triggering event occurs at the time when the Appellant knew or should have known of such condition or circumstance for appeal.  (LD-2 forms are for provider grievances and LD-3 forms are for nursing home wage enhancement grievances.)
  • (B) If the LD form is not received within 20 days of the triggering event, OHCA sends the Appellant a letter stating the appeal will not be heard because it is untimely.
  • (C) The staff advises the Appellant that if there is a need for assistance in reading or completing the grievance form that arrangements will be made.
  • (D) A decision will be rendered by the ALJ ordinarily within 45 days of the close of all evidence in the case.
  • (E) Unless an exception is provided in 317:2-1-13, the Administrative Law Judge's decision is appealable to OHCA's CEO under 317:2-1-13.

(c) ALJ jurisdiction.  The administrative law judge has jurisdiction of the following matters:

• (1) Member Appeals:
  • (A) Discrimination complaints regarding the SoonerCare program;
  • (B) Appeals which relate to the scope of services, covered services, complaints regarding service or care, enrollment, disenrollment, and reenrollment in the SoonerCare Program;
  • (C) Fee for Service appeals regarding the furnishing of services, including prior authorizations;
  • (D) Appeals which relate to the tax warrant intercept system through the Oklahoma Health Care Authority. Tax warrant intercept appeals will be heard directly by the ALJ. A decision will be rendered by the Administrative Law Judge within 20 days of the hearing before the ALJ;
  • (E) Complaints regarding the possible violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA);
  • (F) Proposed administrative sanction appeals pursuant to 317:35-13-7.  Proposed administrative sanction appeals will be heard directly by the ALJ.  A decision by the ALJ will ordinarily be rendered within 20 days of the hearing before the ALJ. This is the final and only appeals process for proposed administrative sanctions;
  • (G) Appeals which relate to eligibility determinations made by OHCA;
  • (H) Appeals of insureds participating in Insure Oklahoma which are authorized by 317:45-9-8(a); and
• (2) Provider Appeals:
  • (A) Whether Pre-admission Screening and Resident Review (PASRR) was completed as required by law;
  • (B) Denial of request to disenroll member from provider's SoonerCare Choice panel;
  • (C) Appeals by Long Term Care facilities for nonpayment of wage enhancements, determinations of overpayment or underpayment of wage enhancements, and administrative penalty determinations as a result of findings made under 317:30-5-131.2(b)(5), (e)(8), and (e)(12);
  • (D) Petitions for Rulemaking;
  • (E) Appeals to the decision made by the Contracts manager related to reports of supplier non-compliance to the Central Purchasing Division, Oklahoma Department of Central Services and other appeal rights granted by contract;
  • (F) Drug rebate appeals;
  • (G) Nursing home contracts which are terminated, denied, or non-renewed;
  • (H) Proposed administrative sanction appeals pursuant to 317:30-3-19.  Proposed administrative sanction appeals will be heard directly by the ALJ. A decision will normally be rendered by the ALJ within 20 days of the hearing before the ALJ. This is the final and only appeals process for proposed administrative sanctions;
  • (I) Contract award appeals;
  • (J) Provider appeals of OHCA audit findings pursuant to 317:2-1-7.  This is the final and only appeals process for appeals of OHCA audits; and
  • (K) Oklahoma Electronic Health Records Incentive program appeals related only to incentive payments, incentive payment amounts, provider eligibility determinations, and demonstration of adopting, implementing, upgrading, and meaningful use eligibility for incentives.
  • (L) Supplemental Hospital Offset Payment Program (SHOPP) annual assessment, Supplemental Payment, fees or penalties as specifically provided in OAC 317:2-1-15.