R410-14-3. Administrative Adjudicative Procedures

  (1) Except as provided in this rule or as otherwise designated by rule or statute or converted pursuant to Subsection 63G-4-202(3), all adjudicative proceedings conducted pursuant to this rule are informal proceedings.

  (2) Request for Agency Action. An aggrieved person may file a written request for agency action pursuant to Utah Code Ann. Section 63G-4-201, and in accordance with this rule.

  (a) A provider may file a written request for agency action without the consent of the recipient or MCO enrollee if the request for agency action pertains to the denial of an authorization for service or a denial of payment on a claim.

  (b) A provider may not file a request for agency action if the request for agency action pertains to the denial, change or termination of eligibility of a member or enrollee for a medical assistance program.

  (3) If a medical issue is in dispute, each request shall include supporting medical documentation. DMHF shall schedule a hearing only when it receives sufficient medical records and may dismiss a request for agency action if it does not receive supporting medical documentation in a timely manner.

  (4) Notice of Agency Action.

  (a) An agency shall provide a written notice of action to each aggrieved person. Such actions include but are not limited to:

  (i) eligibility for assistance;

  (ii) scope of service;

  (iii) denial or limited prior authorization of a requested service including the type or level of service; and

  (iv) payment of a claim.

  (b) The notice must include:

  (i) a statement of the action the agency intends to take;

  (ii) the date the intended action becomes effective;

  (iii) the reasons for the intended action;

  (iv) the specific regulations that support the action, or the change in federal law, state law or DMHF policy which requires the action;

  (v) the right to request a hearing;

  (vi) the right to represent oneself, the right to legal counsel, or the right to use another representative at the hearing; and

  (vii) if applicable, an explanation of the circumstances under which reimbursement for medical services will continue or may be reinstated pursuant to this rule.

  (c) The agency shall mail the notice at least 10 calendar days before the date of the intended action except:

  (i) the agency may mail the notice not later than the date of action in accordance with 42 CFR 431.213;

  (ii) the agency may shorten the period of advance notice to five days before the date of action if it has facts that indicate it must take action due to probable fraud by the recipient or provider and the facts have been verified by affidavit.