Library: Policy

317:2-3-9. Exhaustion of CE or DBM appeals

Issued 7-1-23

(a) Deemed exhaustion of CE or DBM appeals. If the CE and DBM fails to adhere to any timing or notice requirements as detailed in 42 C.F.R. § 438.408, the member is deemed to have exhausted the CE's or DBM's appeal process, and the member or the member's authorized representative may request a state fair hearing.

(b) Actual exhaustion of CE or DBM appeals. Except as allowed in (a), a member or the member's authorized representative may request a state fair hearing only after receiving notice from the CE and DBM upholding an adverse benefit determination and only within one hundred twenty (120) days after the date of the notice of appeal resolution.

(c) Exhaustion of CE or DBM appeals, determination. OHCA has sole authority to decide whether CE and DBM appeals have been exhausted for any member. Documentation, as submitted to OHCA by the CE and DBM within fifteen (15) calendar days of the request for state fair hearing, will serve as evidence to deemed exhaustion, actual exhaustion, or no exhaustion of the CE and DBM appeals process.