Library: Policy

3172-3-9. Exhaustion of managed care entitty appeals

Revised 9-12-22

(a) Deemed exhaustion of MCE appeals. If the MCE 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 MCE's appeal process, and the member or the member's authorized representative may request a State fair hearing.

(b) Actual exhaustion of MCE 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 MCE 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 MCE appeals, determination. OHCA has sole authority to decide whether MCE appeals have been exhausted for any member. Documentation, as submitted to OHCA by the MCE 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 MCE appeals process.