SECTION 317:2-1-12. For cause and immediate provider contract termination appeals process

  This section explains the appeals process for providers whose SoonerCare contracts have been terminated by the Oklahoma Health Care Authority (OHCA) for cause.

(1)   Thirty (30) day for cause termination. Pursuant to the terms of all provider contracts with the OHCA, either party may terminate the contract for cause with a thirty (30) day written notice to the other party.

(A)   Notice of proposed termination. The OHCA will provide notice to the provider of the proposed termination of the provider's contract. The written notice of termination will state:

(i)   the reasons for the proposed termination;

(ii)   the date upon which the termination will be effective; and

(iii)   a statement that the provider has a right to OHCA review prior to the termination of the provider's contract.

(B)   Right to OHCA review prior to termination of provider contract. Before the provider's contract is terminated, the OHCA will give the provider the opportunity to submit documents and written arguments against the termination of the provider's contract. The provider's written response requesting a review must be submitted within thirty (30) days from the date of the notice. If a written response is not received within thirty (30) days, the notice of termination will become final and there will be no further right to review or appeal post-termination.

(C)   Notice of termination.

(i)   After the OHCA review of the provider's written response, the OHCA will make a final administrative decision regarding the contract termination.

(ii)   Should the OHCA decide that the provider's contract should not be terminated, the provider will be notified in writing of the reasons for the OHCA's decision.

(iii)   Should the OHCA make a decision to terminate the provider's contract, the OHCA will send a subsequent notice stating:

(I)   the reasons for the decision;

(II)   the effective date of the termination of the contract; and

(III)   the provider's right to request a post termination panel committee desk review within thirty (30) days of the date of the termination letter.

(2)   Immediate termination. The OHCA will provide notice to the provider of the termination of the provider's contract. The written notice of termination will state:

(A)   the reasons for the proposed termination;

(B)   the date upon which the termination will be effective; and

(C)   a statement that the provider has a right to appeal the termination of the provider's contract in a post-termination panel committee desk review within thirty (30) days of the date of the termination letter.

(3)   Post-termination panel committee desk review. After the effective date of the termination of the provider's contract, the provider is entitled to receive a post-termination panel committee desk review. The panel review committee for the OHCA will be comprised of three (3) employees of the OHCA as designated by the Chief Executive Officer or his/her designee. Any OHCA employee who was involved with the underlying investigation of the provider's case for purpose of the termination will not be a panel review committee member. The purpose and scope of the panel committee desk review will be limited to issues raised in the OHCA's letter of termination as the basis of terminating the provider's contract. The panel committee does not have jurisdiction to hear issues not addressed in the termination notice.

(A)   The provider must request a panel committee desk review within thirty (30) days of the date of the termination letter. The provider must submit a brief written statement detailing the facts which are refuted by the provider. Any documentation the provider requests consideration of by the panel review committee must also be submitted with the written statement.

(B)   The OHCA may submit any additional documents to the panel committee for the desk review that may contradict the documents submitted by the provider for the purposes of the desk review. Any additional information that OHCA submits to the panel review committee will also be provided to the provider.

(C)   The panel review committee will issue a written decision regarding the provider's contract termination approximately sixty (60) days from receipt of the provider's written statement and documentation.

(4)   Sixty (60) day without cause termination. Pursuant to the terms of all provider contracts with the OHCA, either party may terminate the contract without cause with a sixty (60) day written notice to the other party. As such, there is no right to appeal or review of a sixty (60) day contract termination.

[Source: Added at 23 Ok Reg 761, eff 3-9-06 (emergency); Added at 23 Ok Reg 2430, eff 6-25-06; Amended at 26 Ok Reg 3020, eff 7-21-09 (emergency); Amended at 27 Ok Reg 925, eff 5-13-10; Amended at 33 Ok Reg 788, eff 9-1-16; Amended at 36 Ok Reg 850, eff 9-1-19]