In this chapter:

1. 'Adverse benefit determination' means, in the case of a managed care organization, any of the following:

1. a. The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit;
2. b. The reduction, suspension, or termination of a previously authorized service;
3. c. The denial, in whole or in part, of payment for a service;
4. d. The failure to provide services in a timely manner, as defined by the department;
5. e. The failure of a managed care organization to act within the time frames provided in 42 CFR 438.408(b)(1) and (2) regarding the standard resolution of grievances and appeals;
6. f. For a resident of a rural area with only one managed care organization, the denial of an enrollee's request to exercise the right under 42 CFR 438.52(b)(2) to obtain services outside the network; or
7. g. The denial of an enrollee's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities.- 2. 'Appeal' means a specific request for departmental review, by a dissatisfied applicant, recipient, provider, resident, registrant, or licensee concerning a decision made by a human service zone, division of the department, or nursing facility.
8. 1. 'Appeal hearing' means an administrative procedure by which the department reviews a decision by considering evidence and argument presented by a claimant, by the entity that made the decision appealed from, or by authorized representatives of either.
9. 1. 'Appeals supervisor' means the official designated by the department to be responsible for the administration of this chapter.
10. 1. 'Authorized representative' means an individual, including an attorney at law, who has been authorized by the claimant or has legal authority to act for and represent the claimant in any and all aspects of a hearing. The claimant need not designate an authorized representative.
11. 1. 'Claimant' means a person who has perfected an appeal.
12. 1. 'Date of action' means the date upon which an action is intended to become effective.
13. 1. 'Department' means the North Dakota department of human services.
14. 1. 'Developmental disability provider' means the entity that has received authorization by the department, pursuant to North Dakota Century Code chapter 25-16, to provide a service or services to individuals with developmental disabilities.
15. 1. 'Facility' means a nursing facility taking an action to transfer or discharge a resident.
16. 1. 'Fair hearing' means an appeal hearing, established pursuant to 42 U.S.C. 8624(b)(13), 7 CFR 273.15, 42 CFR part 431, subpart D and E, 45 CFR 205.10, or any other federal law or regulation that specifically requires the department to provide a dissatisfied claimant an opportunity for a hearing that meets the requirements for due process of law imposed under Goldberg v. Kelly, 397 U.S. 254 (1970).
17. 1. 'Filing date' of the claimant's appeal, in all cases except supplemental nutrition assistance program and Medicaid appeals, means the postmark date of mailed appeals, the delivery date of delivered appeals, the date of transmission of appeals made by telephone, internet website, and other commonly available electronic means, or, if an oral appeal is permitted, the date of

an oral appeal. The filing date of a request for fair hearing or administrative disqualification hearing in supplemental nutrition assistance program or Medicaid matters means the date the request is received by the department or human service zone.

1. 13. 'Hearing officer' means any person assigned, appointed, or designated to preside in the hearing of an appeal or in an intentional program violation hearing under this chapter.

2. 14. 'Household' means an individual or group of individuals receiving or applying for supplemental nutrition assistance program benefits.

3. 15. 'Human service zone' means a county or consolidated group of counties administering human services within a designated area in accordance with an agreement or plan approved by the department.

4. 16. 'Intentional program violation' means:

1. a. Supplemental nutrition assistance program: 1. (1) Any act or false statement intended to mislead, misrepresent, conceal, or withhold facts; or 2. (2) Commission of any act that constitutes a violation of the Food and Nutrition Act of 2008 [7 U.S.C. 2011-2036], the supplemental nutrition assistance program regulation [7 CFR parts 271-285], or any provision of the North Dakota Century Code relating to the use, presentation, transfer, acquisition, receipt, possession, or trafficking of supplemental nutrition assistance program coupons;

2. b. Temporary assistance for needy families: 1. (1) Any act or false statement intended to mislead, misrepresent, conceal, or withhold facts; 2. (2) Commission of any act intended to mislead, misrepresent, conceal, or withhold facts that constitutes a violation of the temporary assistance for needy families program or any provision of the North Dakota Century Code or federal statute; or 3. (3) Use of temporary assistance for needy families program electronic payment card in a liquor store, a casino, gambling casino, or gambling establishment, or a retail establishment that provides adult-oriented entertainment in which performers disrobe or perform in an unclothed state of environment unless: 1. (a) The temporary assistance for needy families recipient does not have adequate access to their cash assistance other than one of the establishments listed; or 2. (b) The temporary assistance for needy families recipient does not have access to using or withdrawing assistance with a minimal fee or charge, including an opportunity to access assistance with no fee or charge; or

3. c. Child care assistance program: 1. (1) Any act or false statement intended to mislead, misrepresent, conceal, or withhold facts; 2. (2) Commission of any act that constitutes a violation of the child care assistance program; or

(3) The signatures of any provider or caretaker on the application, review form, change report form, child care billing report form, or any other appropriate materials attest to providing factual information that is required to determine eligibility.

17. "Intentional program violation hearing" means a hearing conducted for individuals or households accused of intentional program violations, who do not waive their rights to such a hearing, to determine if the individuals or household members committed, and intended to commit, intentional program violations.

18. "Regulation", as used in 42 CFR 431.210, 431.244, and 45 CFR 205.10(a)(4)(i)(B), includes any written statement of federal or state law or policy, including federal and state constitutions, statutes, regulations, rules, policy manuals or directions, policy letters or instructions, and relevant controlling decisions of federal or state courts.

19. "Request for an intentional program violation hearing" means a written statement from a human service zone, filed at the office of the appeals supervisor, which contains the name, mailing address, and telephone number (if any) of the charged household members or individuals, a detailed statement of charges against household members or individuals, and copies of all available evidence.

20. "Request for fair hearing" means a specialized appeal consisting of any clear written expression or in the case of a request in a supplemental nutrition assistance program matter under 7 CFR 273.15, or in the case of a Medicaid matter under 42 CFR 431.220(a)(1), any clear expression through the telephone, internet website, mail, in person, or through other commonly available electronic means, from a claimant, or the claimant's duly authorized representative, filed with the human service zone or in the office of the appeals supervisor, that the claimant wants the department to conduct a fair hearing to take action concerning the claimant's expressed reasons for dissatisfaction.

21. "Timely notice period" means that period beginning on the date a timely notice is mailed and concluding on the date of action.

History: Effective September 1, 1979; amended effective January 1, 1984; February 1, 1995; April 1, 2018.

General Authority: NDCC 28-32-02, 50-06-16

Law Implemented: NDCC 50-06-05.1