Section R9-34-405. Filing a Claim Dispute for a Claim Involving a Member Enrolled with a Contractor

A.       For a claim for services rendered to a member enrolled with a contractor, the provider shall file a written claim dispute with the contractor under the timelines in A.R.S. § 36- 2903.01(B)(4).

B.       The contractor shall mail a written Notice of Decision of the claim dispute to the provider no later than 30 days after the provider files the claim dispute with the contractor, unless the provider and contractor agree to a longer period.

C.     The contractor's written Notice of Decision shall include:

1.       The date of the decision,

2.        The factual and legal basis for the decision,

3.        The provider's right to request a State Fair Hearing under

A.R.S. § 41-1092, et seq., and

4.        The manner in which a request for a State Fair Hearing is filed under A.R.S. § 41-1092, et seq.

D.       A provider may request a State Fair Hearing on the contrac­ tor's Notice of Decision if:

1.       The provider files a written request for a State Fair Hear­ ing with the contractor no later than 30 days after the date the provider receives the contractor's written Notice of Decision, or

2.        The contractor does not render a written Notice of Deci­ sion within 30 days after the claim dispute is filed and the provider files a written request for a State Fair Hearing within 30 days after the date that the Notice of Decision should have been mailed.

E.       AHCCCS shall mail a Notice of Hearing under A.R.S. § 41-

1092.05 to the parties if a contractor receives a timely request for hearing from the provider.

F.        AHCCCS shall mail a Director's Decision to the provider no later than 30 days after the date the Administrative Law Judge sends the OAH decision to AHCCCS.

G.      AHCCCS shall accept a written request for withdrawal if the written request for withdrawal is received from the provider before AHCCCS mails a Notice of Hearing under A.R.S. § 41- 1092, et seq. If AHCCCS mailed a Notice of Hearing under

A.R.S.  § 41-1092,  et seq., a provider   shall send a written request for withdrawal to OAH.

Historical Note

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