Arizona Administrative Code Title 9, C



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Arizona Administrative Code Title 9, Ch. 34

Arizona Health Care Cost Containment System – Grievance System

TITLE 9. HEALTH SERVICES

CHAPTER 34. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
GRIEVANCE SYSTEM


Editor’s Note: New 9 A.A.C. 34 made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

ARTICLE 1. REQUEST FOR ELIGIBILITY HEARING

Article 1, consisting of R9-34-101 through R9-34-114, made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

Section

R9-34-101. Purpose

R9-34-102. Definitions

R9-34-103. Computation of Time

R9-34-104. Petitioner’s Rights

R9-34-105. Who May File

R9-34-106. Requesting a State Fair Hearing

R9-34-107. Time-frame for Requesting a State Fair Hearing

R9-34-108. Format and Contents of the Request for a State Fair Hearing

R9-34-109. Notice of Hearing

R9-34-110. Denial of a Request for a State Fair Hearing

R9-34-111. AHCCCS Time-frame for Resolution of a State Fair Hearing

R9-34-112. Withdrawal of a Request for a State Fair Hearing

R9-34-113. Motion for Rehearing or Review

R9-34-114. AHCCCS Coverage During the State Fair Hearing Process

ARTICLE 2. APPEAL, GRIEVANCE, AND HEARING FOR AN ENROLLED PERSON

Article 2, consisting of R9-34-201 through R9-34-225, made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

Section

R9-34-201. Purpose

R9-34-202. Definitions

R9-34-203. Computation of Time

R9-34-204. Language and Format of the Notice of Action

R9-34-205. Content of the Notice of Action

R9-34-206. Contractor Notice of Action Time-frame for Service Authorization Requests

R9-34-207. Contractor Notice of Action Time-frame for Service Termination, Suspension, or Reduction

R9-34-208. Who May File

R9-34-209. Enrollee Time-frame for Filing an Appeal or Grievance with the Contractor

R9-34-210. Contractor General Requirements for Grievance or Appeal Process

R9-34-211. Contractor Special Requirements for the Appeal Process

R9-34-212. Contractor Time-frame for Standard Disposition of a Grievance

R9-34-213. Contractor Time-frame for Standard Resolution of an Appeal

R9-34-214. Contractor Process for an Expedited Resolution of an Appeal

R9-34-215. Contractor Time-frame for an Expedited Appeal Resolution

R9-34-216. Content of Contractor Notice of Appeal Resolution

R9-34-217. Enrollee Request for a State Fair Hearing

R9-34-218. AHCCCS Time-frame for Resolution of a State Fair Hearing

R9-34-219. Enrollee’s Request for an Expedited State Fair Hearing

R9-34-220. AHCCCS Time-frame for Resolution of Expedited State Fair Hearing

R9-34-221. Withdrawal of a Request for a State Fair Hearing

R9-34-222. Denial of a Request for a State Fair Hearing

R9-34-223. Motion for Rehearing or Review

R9-34-224. Continuation of Services While the Contractor Appeal and the State Fair Hearing are Pending

R9-34-225. Reversed Appeal Resolutions

ARTICLE 3. APPEAL AND HEARING FOR AN FFS MEMBER

Article 3, consisting of R9-34-301 through R9-34-322, made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

Section

R9-34-301. Purpose

R9-34-302. Definitions

R9-34-303. Computation of Time

R9-34-304. Language and Format of the Notice of Action

R9-34-305. Content of the Notice of Action

R9-34-306. Time-frame for Notice of Action for Service Authorization Requests

R9-34-307. Time-frame for Notice of Action for Service Termination, Suspension, or Reduction

R9-34-308. Who May File

R9-34-309. Time-frame for Filing an Appeal

R9-34-310. General Requirements for the Appeal Process

R9-34-311. Special Requirements for the Appeal Process

R9-34-312. Time-frame for Standard Resolution of an Appeal

R9-34-313. Content of the Notice of Appeal Resolution

R9-34-314. Request for a State Fair Hearing

R9-34-315. Time-frame for Resolution of State Fair Hearing for a Standard Resolution of an Appeal

R9-34-316. Request for Expedited Resolution of an Appeal

R9-34-317. Time-frame for Resolution of Expedited State Fair Hearing

R9-34-318. Withdrawal of a Request for a State Fair Hearing

R9-34-319. Denial of a Request for a State Fair Hearing

R9-34-320. Motion for Rehearing or Review

R9-34-321. Continuation of Services While the Appeal and the State Fair Hearing are Pending

R9-34-322. Reversed Appeal Resolutions

ARTICLE 4. CLAIM DISPUTE

Article 4, consisting of R9-34-401 through R9-34-409, made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

Section

R9-34-401. Purpose

R9-34-402. Definitions

R9-34-403. Computation of Time

R9-34-404. Content of Claim Dispute

R9-34-405. Filing a Claim Dispute for a Claim Involving a Member Enrolled with a Contractor

R9-34-406. Filing a Claim Dispute from a Contractor for Reinsurance

R9-34-407. Filing a Claim Dispute for a Claim Involving an FFS Member

R9-34-408. Denial of a Request for a State Fair Hearing

R9-34-409. Motion for Rehearing or Review

ARTICLE 1. REQUEST FOR ELIGIBILITY HEARING

Article 1, consisting of R9-34-101 through R9-34-114, made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-101. Purpose

This Article establishes the requirements and process for a petitioner to request a State Fair Hearing regarding an adverse action affecting eligibility. Except for the adverse action in R9-34-102(A)(5), this Article does not apply to a person determined eligible by the Arizona Department of Economic Security under 9 A.A.C. 22, Article 14.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-102. Definitions

A. “Adverse action” by AHCCCS means:

1. Denial of eligibility,

2. Discontinuance of eligibility,

3. The imposition of or increase in Arizona Long Term Care System (ALTCS) share of cost determined under A.A.C. R9-28-408 or R9-28-410,

4. An eligibility determination that the petitioner claims is beyond the established time-frame, or

5. The imposition of or increase in a premium or copayment.

B. “AHCCCS” means the AHCCCS Administration as defined in A.R.S. § 36-2901.

C. “Day” means calendar day unless otherwise specified.

D. “Director” means the Director of the Arizona Health Care Cost Containment System Administration or designee.

E. “Director’s Decision” means the final administrative decision under A.R.S. § 41-1092(5).

F. “Filed” means the date that AHCCCS receives a request for a State Fair Hearing as established by a date stamp on the request or other record of receipt.

G. “Petitioner” means applicant, member, or other representative who is described and discussed in A.A.C. R9-22-1501, R9-22-1704, R9-22-1903, R9-22-2004, R9-27-302, R9-28-401, R9-28-1303, R9-29-203, R9-31-302, R9-31-1702, or for an adverse action under subsection (A)(5), an applicant, member, or other representative under 9 A.A.C. 22, Article 14.

H. “State Fair Hearing” means an administrative hearing under A.R.S. Title 41, Chapter 6, Article 10.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-103. Computation of Time

A. Computation of time begins the day after the date on the Notice of Adverse Action and includes all calendar days and the final day of the period. If the final day of the period is a weekend or legal holiday, the period is extended until the end of the next day that is not a weekend or a legal holiday.

B. The 30-day time-frame for filing a request for a State Fair Hearing begins with the date the petitioner receives the Notice of Adverse Action.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-104. Petitioner’s Rights

AHCCCS shall allow a petitioner the right to:

1. A State Fair Hearing; and

2. Copies, at the petitioner’s expense, of any relevant document not protected from disclosure by law.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-105. Who May File

A petitioner who requests a State Fair Hearing shall make the request according to this Article.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-106. Requesting a State Fair Hearing

A petitioner may request a State Fair Hearing under this Article only for an adverse action.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-107. Time-frame for Requesting a State Fair Hearing

A petitioner shall request a State Fair Hearing in writing with AHCCCS within 30 days after the petitioner receives the Notice of Adverse Action.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-108. Format and Contents of the Request for a State Fair Hearing

A petitioner shall submit a written request for a State Fair Hearing to AHCCCS. The request shall contain the case name, the adverse action taken by AHCCCS, and the reason for the State Fair Hearing.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-109. Notice of Hearing

AHCCCS shall mail a Notice of Hearing under A.R.S. § 41-1092.05 if AHCCCS receives a request for a State Fair Hearing that is timely and contains the information listed in R9-34-108.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-110. Denial of a Request for a State Fair Hearing

AHCCCS shall deny a request for a State Fair Hearing upon written determination by AHCCCS that:

1. The request for a State Fair Hearing is untimely;

2. The request for a State Fair Hearing is not for an adverse action permitted under this Article;

3. The request for a State Fair Hearing is moot, as determined by AHCCCS, based on the factual circumstances of the case; or

4. The sole issue presented is a federal or state law requiring an automatic change adversely affecting some or all applicants or members.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-111. AHCCCS Time-frame for Resolution of a State Fair Hearing

AHCCCS shall mail a Director’s Decision to the petitioner no later than 30 days after the date of the Administrative Law Judge’s recommended decision and within 90 days after the date that the petitioner filed the request for a State Fair Hearing not including days for continuances granted at the petitioner’s request.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-112. Withdrawal of a Request for a State Fair Hearing

A. AHCCCS shall accept a written request for withdrawal if the written request for withdrawal is received from the petitioner before AHCCCS mails a Notice of Hearing under R9-34-109.

B. If AHCCCS mailed a Notice of Hearing under R9-34-109, the petitioner shall send a written request for withdrawal to the Office of Administrative Hearings (OAH).

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-113. Motion for Rehearing or Review

Under A.R.S. § 41-1092.09, the Director shall grant a rehearing or review for any of the following reasons materially affecting a petitioner’s rights:

1. Irregularity in the proceedings of a State Fair Hearing that deprived a petitioner of a fair hearing;

2. Misconduct of AHCCCS, OAH, or a party;

3. Newly discovered material evidence that could not, with reasonable diligence, have been discovered and produced at the hearing;

4. The decision is the result of passion or prejudice;

5. The decision is not justified by the evidence or is contrary to law; or

6. Good cause is established for the nonappearance of a party at the hearing.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-114. AHCCCS Coverage During the State Fair Hearing Process

A. If a petitioner requests a State Fair Hearing because of an increase in the share-of-cost, premium, or copayment and the request is filed before the effective date of the increase, AHCCCS shall not enforce the increase until a Director’s Decision is rendered that supports the increase.

B. If a petitioner files a request for a State Fair Hearing for a discontinuance action before the effective date of the discontinuance, the petitioner shall continue to receive AHCCCS coverage until a Director’s Decision is rendered. A petitioner may waive coverage while the Director’s Decision is pending.

C. A petitioner, eligible under 9 A.A.C. 22, Article 31, who requests AHCCCS coverage during the State Fair Hearing process, shall comply with the premium payment requirements under A.A.C. R9-31-1419.

D. A petitioner whose benefits are continued shall be financially liable for all fee-for-service and capitation payments made by AHCCCS during a period of ineligibility, if a discontinuance decision is upheld under A.R.S. § 41-1092.08.

E. If a petitioner requests a hearing regarding the termination of family planning services under A.A.C. R9-22-1424 or the guaranteed enrollment period under 9 A.A.C. 22, Article 17, the petitioner shall not continue to be AHCCCS eligible after the end of the designated time period under A.R.S. § 36-2907.04 and 42 U.S.C. 1396a(e)(2). If the termination of family planning services is overturned, the applicable effective date of AHCCCS coverage shall be set forth in the Director’s Decision.

F. If a denial of eligibility is overturned, the effective date of AHCCCS eligibility shall be set forth in the Director’s Decision.



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