1. (1) Except as provided in this rule or otherwise designated by rule or statute or converted pursuant to Subsection 63G-4-202(3), each adjudicative proceeding conducted pursuant to this rule shall be designated an informal adjudicative proceeding.

2. (2) An aggrieved person may file a written request for agency action, pursuant to Subsections 63G-4-201(3)(a) and (b) and in accordance with this rule.

   1. (a) A provider may file a written request for agency action without the consent of the member or MCO enrollee if the request for agency action pertains to the denial of an authorization for service or a denial of payment on a claim.
   2. (b) A provider may not file a request for agency action if the request for agency action pertains to the denial, change, or termination of eligibility of a member for a medical assistance program.
3. (3) If a medical issue is in dispute, each request shall include supporting medical documentation. The office may schedule a hearing only when it receives sufficient medical records and may dismiss a request for agency action if it does not receive supporting medical documentation in a timely manner.

4. (4) An agency shall provide a written notice of action to each aggrieved person. These actions include:

   1. (a) denial or limited prior authorization of a requested service including the type or level of service;
   2. (b) eligibility for assistance;
   3. (c) payment of a claim; and
   4. (d) scope of service.

5. (5) The notice shall include:

   1. (a) a statement of the action the agency intends to take;
   2. (b) the date the intended action becomes effective;
   3. (c) the reasons for the intended action;
   4. (d) the specific regulations that support the action, or the change in federal law, state law, or DIH policy which requires the action;
   5. (e) the right to request a hearing;
   6. (f) the right to represent oneself, the right to legal counsel, or the right to use another representative at the hearing; and
   7. (g) if applicable, an explanation of the circumstances under which reimbursement for medical services will continue or may be reinstated pursuant to this rule.

6. (6) The agency shall mail the notice at least ten calendar days before the date of the intended action except that:

   1. (a) the agency may mail the notice before the date of action in accordance with 42 CFR 431.213 (2025); and
   2. (b) the agency may shorten the period of advance notice to five days before the date of action if the agency has facts that indicate the agency shall take action due to probable fraud by the member or provider and the facts have been verified by affidavit.

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