3701-44-07 Reconsideration process for denial or termination of eligibility.

(A) The following individuals may seek reconsideration of a denial or termination decision pertaining to the Ryan White part B program:

(1) An individual who has applied for eligibility for benefits and whose application has been denied;

(2) An individual eligible for Ryan White part B program who has been denied payment for a requested service or whose eligibility determination has been terminated;

(3) An individual or entity who has been denied a provider agreement; and

(4) A provider whose provider agreement has been terminated.

(B) An individual seeking reconsideration of a decision listed in paragraph (A) of this rule shall file a written request for reconsideration with the HIV medical case manager or director as directed in writing by the agency issuing the adverse decision. The request for reconsideration must be received within thirty days from the date the individual or entity received the denial or termination decision from the HIV medical case manager or director. The request for reconsideration must contain a statement of the reasons that the individual or entity believes that the denial or termination decision is incorrect or inconsistent with the Ryan White part B program requirements, and may include any written documentation, arguments or other materials that the affected party wishes to submit for the purposes of the reconsideration.

(1) Review the information submitted by the individual or entity within thirty days of receipt of the request. The review may request additional information from the individual or entity. The individual or entity shall submit additional information within forty-five days of receiving a request for additional information.

(2) Submit a written decision to the individual or entity who requested the reconsideration within thirty days of the receipt of the request for reconsideration or receipt of additional information, whichever is later. The written decision shall include the reasons for the decision and the following information:

(a) If the decision was made by the director, the notice shall state that the decision is final and there is no further review.

(b) If the decision was made by the HIV case manager, the notice shall state that the individual or entity affected by the decision may request further review by the director by submitting a written request for review of the HIV case manager’s decision to the director within thirty days of receipt of the HIV case manager’s decision.

(3) Upon timely receipt of a request to review HIV case manager’s decision, the director shall review the record and issue a final written decision to the individual or entity within thirty days of receipt of the request.

Replaces: 3701-44-07, 3701-44-13

Effective: 08/02/2009

R.C. 119.032 review dates: 08/01/2014

Promulgated Under: 119.03

Statutory Authority: 3701.241

Rule Amplifies: 3701.241

Prior Effective Dates: 9/23/91 (Emer), 12/22/91, 5/20/1999, 7/20/2001