Section R9-34-111. AHCCCS Time-frame for Resolution of a State Fair Hearing

AHCCCS shall mail a Director's Decision to the petitioner no later than 30 days after the date of the Administrative Law Judge's rec-

Administrative Code                                                                  Title      Ch. 34

Arizona Health Care Cost Containment System - Grievance System

ommended decision and within 90 days after the date that the peti­ tioner filed the request for a State Fair Hearing not including days for continuances granted at the petitioner's request.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-112.     Withdrawal of a Request for a State Fair Hearing

A.       AHCCCS shall accept a written request for withdrawal if the written request for withdrawal is received from the petitioner before AHCCCS mails a Notice of Hearing under R9-34-109.

B.       IfAHCCCS mailed a Notice of Hearing under R9-34-109, the petitioner shall send a written request for withdrawal to the Office of Administrative Hearings (OAH).

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-113.    Motion for Rehearing or Review

Under A.R.S. § 41-1092.09, the Director shall grant a rehearing or review for any of the following reasons materially affecting a peti­ tioner's rights:

1.       Irregularity in the proceedings of a State Fair Hearing that deprived a petitioner of a fair hearing;

2.        Misconduct of AHCCCS, OAH, or a party;

3.       Newly discovered material evidence that could not, with reasonable diligence, have been discovered and produced at the hearing;

4.        The decision is the result of passion or prejudice;

5.       The decision is not justified by the evidence or is contrary to law; or

6.        Good cause is established for the nonappearance of a party at the hearing.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-114. AHCCCS Coverage During the State Fair Hear- ing Process

A.       If a petitioner requests a State Fair Hearing because of an increase in the share-of-cost, premium, or copayrnent and the request is filed before the effective date of the increase, AHC­ CCS shall not enforce the increase until  a Director's Decision is rendered that supports the increase.

B.       If a petitioner files a request for a State Fair Hearing for a dis­ continuance action before the effective date of the discontinu­ ance, the petitioner shall continue to receive AHCCCS coverage until a Director's Decision is rendered. A petitioner may waive coverage while the Director's Decision is pending.

C. A petitioner, eligible under 9 A.A.C. 22, Article 31, who requests AHCCCS coverage during the State Fair Hearing pro­ cess, shall comply with the premium payment requirements under A.A.C. R9-31-1419.

D.       A petitioner whose benefits are continued shall be financially liable for all fee-for-service and capitation payments made by AHCCCS during a period of ineligibility, if a discontinuance decision is upheld under A.R.S. § 41-1092.08.

E.       If a petitioner requests a hearing regarding the termination of family planning services under A.A.C. R9-22-1424 or the guaranteed enrollment period under 9 A.A.C. 22, Article 17, the petitioner shall not continue to be AHCCCS eligible after the  end of the designated   time period  under  A.R.S.  § 36-

2907.04 and 42 U.S.C. 1396a(e)(2). If the termination of fam­ ily planning  services is overturned, the applicable effective date of AHCCCS coverage shall be set forth in the Director's Decision.

F.        If a denial of eligibility is overturned, the effective date of AHCCCS eligibility shall be set forth in the Director's Deci­ sion.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

ARTICLE 2. APPEAL, GRIEVANCE, AND HEARING FOR AN ENROLLED PERSON

Article 2, consisting of R9-34-201 through R9-34-225, made byfinal rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp.

04-1).

R9-34-201.      Purpose

This Article establishes the grievance, appeal, and State Fair Hear­ ing requirements for a person enrolled with an AHCCCS contrac­ tor. A contractor is responsible for any functions or responsibilities delegated under a subcontract. It is the contractor's responsibility to ensure that the subcontractor has the ability to perform the dele­ gated activities.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).

R9-34-202.     Definitions

The following definitions apply for purposes of this Article:

1.        "AHCCCS" means the AHCCCS Administration as defined in A.RS. § 36-2901.

2.       "Action" by a contractor means:

a.        The denial or limited authorization  of a requested service, including the type or level of service;

b.        The reduction, suspension, or termination of a previ­ ously authorized service;

c.        The denial, in whole or in part, of payment for a ser­ vice;

d.        The failure to provide a service in a timely manner as set forth in contract;

e.        The failure of a contractor to act within the time­ frames specified in this Article; or

f.         For an enrollee residing in a rural area with only one contractor, the denial of an enrollee's request to exercise the enrollee's right to obtain services out­ side the contractor's network.

3.        "Appeal" means a request for review of an action.

4.        "Contractor" means contractor or program contractor as defined in A.R.S. § 36-2901, 36-2931, 36-2971 and 36- 2981; the Comprehensive Medical Dental Program in the Department of Economic Security; and the Children's Rehabilitation Services and Behavioral Health Services in the Arizona Department of Health Services.

5.        "Day" means calendar day unless otherwise specified.

6.        "Director" means the Director of the Arizona Health Care Cost Containment System Administration or designee.

7.        "Director's Decision" means the final administrative decision under A.R.S. § 41-1092(5).

8.       "Enrollee" means a person eligible for AHCCCS under

A.R.S. Title 36, Chapter 29 and who is enrolled with an AHCCCS contractor.

9.       "Filed" means the date that the contractor or AHCCCS, whichever is applicable, receives the request as estab­ lished by a date stamp on the request or other record of receipt.

10.    "Grievance" means an expression of dissatisfaction about any matter other than an action. Possible subjects for grievances include, but are not limited to, the quality of care or services provided, and aspects of interpersonal

Arizona Health Care Cost Containment System - Grievance System

relationships such as rudeness of a provider or employee or failure to respect the enrollee's rights.

11.    "Institution for Mental Disease" means an institution defined in 42 CFR 435.1009 and licensed by the Arizona Department of Health Services.

12.    "Rural" has the same meaning as in A.RS. § 36-2171.

13.    "State Fair Hearing"  means an administrative hearing under A.R.S. Title 41, Chapter 6, Article 10.

14.    "Working day" means a Monday, Tuesday, Wednesday, Thursday, or Friday unless:

a.        A legal holiday falls on Monday, Tuesday, Wednes­ day, Thursday, or Friday; or

b.        A legal holiday falls on Saturday or Sunday and a contractor is closed for business the prior Friday or following Monday.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).