Library: Policy

317:2-3-5-1. Continuation of benefits pending appeal and state fair hearing

Issued 7-1-23

(a) Per OAC 317:2-1-2.6 and 42 C.F.R. § 438.420, the CE or DBM shall continue a member's benefits under the plan when all of the following occur:

(1) The member files the request for an appeal within sixty (60) calendar days following the date on the adverse benefit determination notice in accordance with 42 C.F.R. § 438.402(c)(1)(ii) and (c)(2)(ii):

(2) The appeal involves the termination, suspension, or reduction of previously authorized services;

(3) The services were ordered by an authorized provider;

(4) The period covered by the original authorization has not expired; and

(5) The member timely files for continuation of benefits, meaning on or before the later of the following:

(A) Within ten (10) calendar days of the CE or DBM sending the notice of adverse benefit determination; or

(B) The intended effective date of the CE or DBM's proposed adverse benefit determination.

(b) If the member fails to indicate a preference as to continuation or reinstatement of services in a written request for hearing made within sixty (60) calendar days of the adverse benefit determination, services shall be continued or reinstated. Notwithstanding the foregoing, continuation or reinstatement of benefits shall not occur under the following circumstances:

(1) The member has exceeded the limit applicable to the services; or

(2) When a provider has failed to prescribe or order the service or level of service for which continuation or reinstatement is requested.

(1) Files a request for a state fair hearing within one hundred twenty (120) days of the adverse resolution notice; and

(2) Files a request for continuation of benefits within thirty (30) calendar days of the adverse resolution notice.

(d) If the CE or DBM continues or reinstates the member's benefits at the member's request while the appeal or state fair hearing is pending, the benefits must be continued until one (1) of the following occurs:

(1) The member withdraws the appeal or request for state fair hearing;

(2) The member fails to request a state fair hearing and continuation of benefits within ten (10) calendar days after the CE or DBM sends the notice of an adverse resolution to the member's appeal under 42 C.F.R. §§ 438.420 (c)(2) and 438.408 (d)(2); or

(3) A state fair hearing officer issues a hearing decision adverse to the member.