1. (1) Terms in this rule are defined in Rule R414-1 and Section 63G-4-103. Additionally:

2. (2) "Action" means:

   1. (a) a denial or termination of eligibility for participation in a program or as a provider;
   2. (b) a denial, reduction, or revocation of reimbursement for services for a provider;
   3. (c) a denial, reduction, suspension, or termination of medical assistance for a member;
   4. (d) a determination by a skilled nursing facility or nursing facility to transfer or discharge a resident;
   5. (e) an adverse benefit determination, as defined in Subsection R410-14-20(2)(a);
   6. (f) an adverse determination, as defined in Subsection (2)(b); or
   7. (g) the placement of a Medicaid member on the restriction program, as described under Section R414-29-3.

3. (3) "Adverse determination" means a determination, in accordance with Subsection 1919(b)(3)(F) or Subsection 1919(e)(7)(B) of the Social Security Act, that:

   1. (a) an individual does not require the level of services provided by a nursing facility; or
   2. (b) an individual does or does not require specialized services.

4. (4) "Agency" means:

   1. (a) the Division of Integrated Healthcare (DIH) within the Department of Health and Human Services, except the Office of Substance Use and Mental Health;
   2. (b) the Department of Workforce Services (DWS); or
   3. (c) any MCO that conducts or performs an action.
5. (5) "Aggrieved person" means any member, enrollee, or provider who is adversely affected by an action.
6. (6) "Child Health Evaluation and Care" program or "CHEC" means Utah's version of the federally mandated Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Medicaid child health program.
7. (7) "De novo" means anew or considering the question of a case for the first time.
8. (8) "Decision" or "order" means a ruling by a presiding officer that determines the legal rights, duties, privileges, immunities, or other legal interests of a party.
9. (9) "Department" means the Department of Health and Human Services.

10. (10) "Eligibility agency" means:

    1. (a) the department;
    2. (b) DWS; or
    3. (c) any entity the agency contracts with to determine medical assistance eligibility.
11. (11) "Ex parte communication" means direct or indirect communication in connection with an issue of fact or law, between the presiding officer and only one party.

12. (12)(a) "Grievance" means an expression of dissatisfaction about any matter other than an action as defined in this rule.

    1. (b) A grievance may include:

       1. (i) the quality of care of services provided; or
       2. (ii) an aspect of interpersonal relationships, such as rudeness of a provider or employee or the failure to respect the rights of an MCO member.
13. (13) "Grievance system" means the overall process for an MCO to collect, review, and make a determination on a grievance or appeal and for the individual who files an appeal to access the administrative hearing process set out in this rule.
14. (14) "Mail" means to send through mail services, email, fax, or hand-delivery.

15. (15) "Managed care organization" or "MCO" means an entity that:

    1. (a)(i) is a health maintenance organization;

       1. (ii) is a prepaid mental health plan; or
       2. (iii) is a dental managed care plan; and
    2. (b) contracts with DIH to provide health, behavioral health, or oral health services to Medicaid or Children's Health Insurance Program members.
16. (16) "Medical record" means a record that contains medical data of a medical assistance member.
17. (17) "Office" means the Office of Administrative Hearings within the Department of Health and Human Services.

18. (18)(a) "Party" includes:

    1. (i) the agency or an individual designated by the agency head to represent the agency in an adjudicative proceeding;

       1. (ii) an aggrieved person; or
       2. (iii) a claimant.

    2. (b) "Party" does not include:

       1. (i) the general public;
       2. (ii) a witness testifying at an adjudicative proceeding; or
       3. (iii) an Artificial Intelligence (AI) bot, computer, or program.

19. (19) "Presiding officer" means an agency head, or individual designated by the agency head, by rule, or by statute to conduct an adjudicative proceeding and may include:

    1. (a) a division or office director;
    2. (b) a hearing officer;
    3. (c) a statutorily created board or committee;
    4. (d) an administrative law judge; and
    5. (e) the superintendent of an agency institution.
20. (20) "Provider" means any person or entity that is licensed and otherwise authorized to furnish health care to members.
21. (21) "Scope of service" means behavioral, medical, or oral health services under Title R414, Integrated Healthcare, as a covered benefit.
22. (22) "State fair hearing" means an administrative hearing conducted pursuant to this rule.

KEY: Medicaid

Date of Last Change: September 19, 2025

Notice of Continuation: August 12, 2022

Authorizing, and Implemented or Interpreted Law: 26B-1-202(1); 26B-1-204; 63G-4-102