R382-1-8. Agency Conferences, Fair Hearings and Appeals

(1) An applicant or enrollee may request an agency conference in accordance with Section R414-301-5 at any time to resolve a problem without requesting an agency action under the Utah Administrative Procedures Act (UAPA).

(2) The applicant or enrollee, parent, legal guardian, or authorized representative may request an agency action, also called a fair hearing, if he disagrees with an agency decision regarding the individual's eligibility. The request for a fair hearing must be in accordance with the provisions and time limits of Section R414-301-6.

(3) The Department of Workforce Services (DWS) shall conduct fair hearings on eligibility in accordance with the provisions of Section R414-301-6.

(4) If an enrollee disagrees with a decision of the MCO regarding a covered benefit or service, the enrollee may appeal the decision through the MCO.

(a) An enrollee must exhaust grievance remedies with the MCO before he requests an agency action from the Department.

(b) The enrollee may file an appeal with the Department if the enrollee disagrees with the MCO's resolution. The enrollee must file the appeal within 60 days of the date that the MCO sends the resolution notice.

(c) The Department shall conduct a review of the MCO's decision in accordance with the provisions of 42 CFR 438.408 and issue a final decision to the enrollee and the MCO.

(d) The Department shall conduct all appeals in accordance with UAPA.

(e) The enrollee may continue to receive benefits if the enrollee meets the conditions of 42 CFR 438.420.