SECTION 317:2-1-2. Appeals

(a)   Request for appeals.

(1)   For the purpose of calculating the timeframe for requesting an administrative appeal of an agency action, the date on the written notice shall not be included. The last day of the timeframe shall be included, unless it is a legal holiday as defined by Title 25 of the Oklahoma Statutes (O.S.) Section (§) 82.1, or any other day the Oklahoma Health Care Authority (OHCA) is closed or closes early, in which case, the timeframe runs until the close of the next full business day.

(2)   An appeals request that an aggrieved member or provider sends via mail is deemed filed on the date that the agency receives it.

(b)   Member process overview.

(1)   The appeals process allows a member to appeal a decision relating to program benefits. Examples are decisions involving medical services, prior authorizations for medical services, or discrimination complaints.

(2)   In order to initiate an appeal, the member must file a LD-1 (Member Complaint/Grievance Form) within thirty (30) calendar days of the date the OHCA sends written notice of its action, in accordance with Oklahoma Administrative Code (OAC) 317:2-1-2(a), above, or, in matters in which a formal notice is not sent by the agency, within thirty (30) days of the date on which the member knew or should have known the facts or circumstances serving as the basis for appeal.

(3)   If the LD-1 form is not received timely, the administrative law judge (ALJ) will cause to be issued a letter stating the appeal will not be heard. In the case of tax warrant intercept appeals, if the LD-1 form is not received by OHCA within the timeframe pursuant to 68 O.S. § 205.2, OHCA similarly will cause to be issued a letter stating the appeal will not be heard because it is untimely.

(4)   If the LD-1 form is not completely filled out or if necessary documentation is not included, then the appeal will not be heard.

(5)   OHCA will advise members that if assistance is needed in reading or completing the grievance form, arrangements will be made to provide such assistance.

(6)   Upon receipt of the member's appeal, a fair hearing before the ALJ will be scheduled. The member will be notified in writing of the date and time of the hearing. The member must appear at the hearing, either in person or telephonically. Requests for a telephone hearing must be received in writing on OHCA's LD-4 (Request for Telephonic Hearing) form no later than ten (10) calendar days prior to the scheduled hearing date. Telephonic hearing requests will only be granted by the OHCA's chief executive officer (CEO) or his/her designee, at his/her sole discretion, for good cause shown, including, for example, the member's physical condition, travel distances, or other limitations that either preclude an in-person appearance or would impose a substantial hardship on the member.

(7)   The hearing shall be conducted according to OAC 317:2-1-5. The ALJ's decision may be appealed to the CEO of the OHCA, which is a record review at which the parties do not appear (OAC 317:2-1-13).

(8)   Member appeals are ordinarily decided within ninety (90) days from the date on which the member's timely request for a fair hearing is received, unless:

(A)   The appellant was granted an expedited appeal pursuant to OAC 317:2-1-2.5;

(B)   The OHCA cannot reach a decision because the appellant requests a delay or fails to take a required action, as reflected in the record;

(C)   There is an administrative or other emergency beyond OHCA's control, as reflected in the record; or

(D)   The appellant filed a request for an appeal of a denied step therapy exception request, pursuant to OAC 317:2-1-18.

(9)   Tax warrant intercept appeals will be heard directly by the ALJ. A decision is normally rendered by the ALJ within twenty (20) days of the hearing before the ALJ.

(c)   Provider process overview.

(1)   The proceedings as described in this subsection contain the hearing process for those appeals filed by providers. These appeals encompass all subject matter cases contained in OAC 317:2-1-2(d)(2).

(2)   All provider appeals are initially heard by the OHCA ALJ under OAC 317:2-1-2(d)(2).

(A)   In order to initiate an appeal, a provider must file the appropriate LD form within thirty (30) calendar days of the date the OHCA sends written notice of its action, in accordance with OAC 317:2-1-2(a), above. LD-2 forms should be used for Program Integrity audit appeals; LD-3 forms are to be used for all other provider appeals.

(B)   Except for OHCA Program Integrity audit appeals, if the appropriate LD form is not received timely, the ALJ will cause a letter to be issued stating that the appeal will not be heard.

(C)   A decision ordinarily will be issued by the ALJ within forty-five (45) days of the close of all evidence in the appeal.

(D)   Unless otherwise limited by OAC 317:2-1-7 or 317:2-1-13, the ALJ's decision is appealable to OHCA's CEO.

(d)   ALJ jurisdiction. The ALJ 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 OHCA. Tax warrant intercept appeals will be heard directly by the ALJ. A decision will be rendered by the ALJ within twenty (20) days of the hearing;

(E)   Proposed administrative sanction appeals pursuant to OAC 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 twenty (20) days of the hearing before the ALJ. This is the final and only appeals process for proposed administrative sanctions;

(F)   Appeals which relate to eligibility determinations made by OHCA;

(G)   Appeals of insureds participating in Insure Oklahoma which are authorized by OAC 317:45-9-8; and

(H)   Appeals which relate to a requested step therapy protocol exception as provided by 63 O.S. § 7310.

(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 administrative penalty determinations as a result of findings made under OAC 317:30-5-131.2(b)(5)(B) and (d)(8);

(D)   Appeals of Professional Service Contract awards and other matters related to the Central Purchasing Act pursuant to Title 74 O.S. § 85.1 et seq.;

(E)   Drug rebate appeals;

(F)   Provider appeals of OHCA Program Integrity audit findings pursuant to OAC 317:2-1-7. This is the final and only appeals process for appeals of OHCA Program Integrity audit findings;

(G)   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;

(H)   Supplemental Hospital Offset Payment Program (SHOPP) annual assessment, supplemental payment, fees or penalties as specifically provided in OAC 317:2-1-15;

(I)   The Nursing Facility Supplemental Payment Program (NFSPP) and its issues consisting of the amount of each component of the intergovernmental transfer, the Upper Payment Limit payment, the Upper Payment Limit gap, and the penalties specifically provided in OAC 317:30-5-136. This is the final and only process for appeals regarding NFSPP; and

(J)   Appeals from any adjustment made to a long-term care facility's cost report pursuant to OAC 317:30-5-132, including any appeal following a request for reconsideration made pursuant to OAC 317:30-5-132.1.

[Source: Added at 13 Ok Reg 389, eff 11-14-95 (emergency); Added at 13 Ok Reg 893, eff 11-21-95 (emergency); Amended at 13 Ok Reg 2301, eff 4-10-96 (emergency); Added at 13 Ok Reg 1627, eff 5-27-96; Amended at 13 Ok Reg 3179, eff 6-18-96 (emergency); Amended at 14 Ok Reg 1755, eff 5-27-97; Amended at 15 Ok Reg 3771, eff 6-24-98 (emergency); Amended at 16 Ok Reg 1412, eff 5-27-99; Amended at 18 Ok Reg 243, eff 11-21-00 (emergency); Amended at 18 Ok Reg 758, eff 1-23-01 (emergency); Amended at 18 Ok Reg 2949, eff 5-17-01 (emergency); Amended at 19 Ok Reg 2120, eff 6-27-02; Amended at 20 Ok Reg 1919, eff 6-269-03; Amended at 21 Ok Reg 2147, eff 6-25-04; Amended at 23 Ok Reg 761, eff 3-9-06 (emergency); Amended at 23 Ok Reg 2430, eff 6-25-06; Amended at 24 Ok Reg 300, eff 12-1-06 (emergency); Amended at 24 Ok Reg 869, eff 5-11-07; Amended at 27 Ok Reg 702, eff 3-1-10 through 7-14-10 (emergency); Amended at 27 Ok Reg 2733, eff 7-20-10 (emergency); Amended at 28 Ok Reg 7, eff 8-13-10 (emergency); Amended at 28 Ok Reg 259, eff 11-15-10 (emergency); Amended at 28 Ok Reg 1376, eff 6-25-11; Amended at 29 Ok Reg 187, eff 11-22-11 (emergency); Amended at 29 Ok Reg 469, eff 5-11-12; Amended at 33 Ok Reg 783, eff 9-1-16; Amended at 34 Ok Reg 339, eff 12-29-16 (emergency); Amended at 34 Ok Reg 606, eff 9-1-17; Amended at 35 Ok Reg 1378, eff 9-14-18; Amended at 36 Ok Reg 850, eff 9-1-19; Amended at 37 Ok Reg 508, eff 1-6-20 (emergency); Amended at 37 Ok Reg 1465, eff 9-14-20]

Note

EDITOR’S NOTE: This emergency action expired without being superseded by a permanent action. Upon expiration of an emergency amendatory action, the last effective permanent text is reinstated. Therefore, on 7-15-10 (after the 7-14-10 expiration of this emergency action), the text of 317:2-1-2 reverted back to the permanent text that became effective 5-11-07, as last published in the 2009 OAC Supplement, and remained as such until amended again by emergency action on 7-20-10.