1. (1) The office shall conduct informal hearings. The presiding officer may convert the proceeding to a formal hearing if an aggrieved person requests a hearing that meets the criteria set forth in Section 63G-4-202.
2. (2) If a hearing under this rule is converted to a formal hearing pursuant to Section 63G-4-202, the formal hearing shall be conducted in accordance with these criteria except as otherwise provided in Sections 63G-4-204 through 63G-4-208 or other applicable statute.
3. (3) The office shall conduct a hearing in connection with an action if the aggrieved person requests a hearing and there is a disputed issue of fact. If there is no disputed issue of fact, the presiding officer may deny a request for an evidentiary hearing and issue a decision without a hearing based on the record. In the decision, the presiding officer shall specifically set out any material and relevant fact not in dispute.

4. (4)(a) There is no disputed issue of fact if every material fact the agency relied upon in taking the adverse action or in obtaining the relief sought in the adjudicative proceeding is established by:

   1. (i) the aggrieved person's own acknowledgment or admission;

      1. (ii) an adjudication from a court of competent jurisdiction; or
      2. (iii) a record submitted by either party if the aggrieved person does not challenge the record's accuracy.
   2. (b) When the reasonableness of the agency's action is the primary issue under consideration, rather than whether there is a factual basis for the agency's action, the issue of reasonableness remains in dispute even if there is no dispute as to any underlying material fact that resulted in the agency's action.
5. (5) If the aggrieved person objects to the hearing denial, the person may raise that objection as grounds for relief in a request for agency review.
6. (6) An MCO may not require an aggrieved person to use arbitration or mediation to resolve an action. An aggrieved person may file a request for hearing relating to an action regardless of any contractual provision with an MCO that may require arbitration or mediation.
7. (7) The presiding officer may not grant a hearing if the issue is a state or federal law requiring an automatic change in eligibility for medical assistance or covered services that affect the aggrieved person.

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