| SNiP Tips
Solving Problems II: Fair Hearings
What is a fair hearing?
A fair hearing is a state process for settling disputes.
| SNiP Tip: For help with appeals or fair hearings, you or your
client can contact the Managed Care Consumer Assistance Program at GMHC at 212/367-1125;
TTY: 212/367-1199.
|
When can my client ask for a fair hearing?
Enrollees can ask for a fair hearing by telephone from the state Office of
Administrative Hearings (OAH) for the following reasons:
- Local Medicaid office decisions about enrollment, disenrollment, or
eligibility
- Denial, termination, reduction, or suspensions of benefits by the plan
(including when a provider thinks a service is necessary and the plan
disagrees)
- Provider denials of care that the plan agrees with and that have gone
through the internal appeals process
- The plan's failure to respond promptly to a request for services
If the dispute is about services that the enrollee wants, he or
she has to have written notice of a negative decision from the plan
before requesting a fair hearing. A fair hearing has to
be about the health plan's decision, not a provider's.
So, if a doctor denies services, the patient has to go through the
HIV SNP's internal appeals process. If the HIV SNP agrees with the
doctor, the patient can then ask for a fair hearing.
How does the fair hearing process work?
At the fair hearing, the plan or local Medicaid office will give evidence
to support its side. If no one from the plan appears, the plan has to send
written material to OAH and to the enrollee at least three business days
before the scheduled hearing.
If the client is homebound, he or she can ask for a phone or written hearing,
or choose a representative to go to the hearing for them.
The plan has to follow the decision made by OAH at the fair hearing. If the
decision involves a service that was originally denied and the enrollee wins,
the plan can give the service or pay for the service by a non-network provider.
If the enrollee has also pursued an external appeal, the decision at the fair
hearing is the one that counts.
Will my client's disputed benefits be cut off during the fair
hearing process?
To keep a disputed service from being reduced or cut off, your
client has to ask for aid continuing. To get this,
he or she has to ask for the fair hearing within ten days of finding
out that the service is supposed to end or be reduced. If your client
gets aid continuing, this means the plan has to continue to give
the disputed services until the fair hearing process is done or
until the treatment is over.
Can my client pursue both an appeal (or utilization review) and a
fair hearing?
Yes. If your client's complaint is one that can be addressed through both
processes, he or she can pursue a complaint and appeals procedure (or utilization
review), a fair hearing, or both. Both processes can be started right away;
enrollees don't have to go through the whole appeals process before asking for
a fair hearing.
What are the differences between a fair hearing and the appeals
(or utilization review) process?
In situations when your client may be able to choose between the plan's appeals
or utilization review process and a fair hearing, or both, you will want to be
able to tell them about the differences.
First of all, as discussed above, the process you can pick depends on the
type of problem:
- If the problem has to do with eligibility for joining an HIV SNP, or enrollment
and disenrollment issues, your client can ask only for a fair hearing.
- If the problem has to do with a provider's decision, your client has to start
with the complaint and appeals process.
- If the problem has to do with a plan denial, reduction, or termination of
benefits, your client can start with the complaint and appeals process and/or ask
for a fair hearing.
- If the problem has to do with a plan denial based on medical necessity, your
client can ask for a utilization review and/or a fair hearing.
| SNiP Tip: It is important to remind your clients that
only a fair hearing has the possibility of aid continuing. If your client
is worried about a benefit being reduced or cut off, asking for a fair hearing
and for aid continuing can help prevent this.
|
Next > >
Contents
© 2003 Gay Men's Health Crisis
|
home 
