360-6.5 Fair hearing requirements in utilization review cases.
When a utilization review committee determines that MA payments should be reduced or
discontinued, the following steps must taken:
(a) If the recipient is in a long-term care facility (a skilled nursing
facility, intermediate care facility or mental hospital) or is a chronic care patient in a
general hospital facility:
(1) the recipient, his/her representative, or
an appropriate relative must notified of the action in writing by the utilization review
committee. The notice must be both timely and adequate as defined in Part 358 of this
Title. The notice and action must be consistent with both State and federal requirements
on utilization review.
(2) If the recipient requests a fair hearing
before the effective date of the action, payment for the recipient's care in a long- term
care facility or for long-term care in a general hospital will be continued until the fair
hearing decision is rendered.
(b) If the recipient is in a general hospital, but not receiving
chronic care services:
(1) The recipient, his/her representative, or
an appropriate relative must be notified of the action in writing by the utilization
review committee. The notice must be adequate, as defined in Part 358 of this Title. The
notice and action must be consistent with both State and federal requirements on
utilization review.
(2) MA payments on behalf of the recipient will
be terminated on the effective date of the utilization review committee determination.
(3) MA payments will not be continued on behalf
of the recipient if the recipient requests a fair hearing to contest a determination that
hospitalization is no longer necessary.
(c) All provisions of Part 358 of this Title which are not inconsistent
with subdivisions (a) and (b) of this section apply to utilization review committee
determinations.