1. (1) The office shall schedule a prehearing conference in a timely manner after the office receives the request for a hearing.

2. (2) The purpose of the prehearing conference is to:

   1. (a) arrange for the exchange of proposed exhibits or prepared expert testimony;
   2. (b) formulate or simplify the issues;
   3. (c) obtain admissions of fact and documents that will avoid unnecessary proof;
   4. (d) outline procedures for the hearing; or
   5. (e) agree to other matters that may expedite the orderly conduct of the hearing or settlement.

3. (3) The presiding officer may request a review of the medical record by a DIH CHEC Utilization Review committee to evaluate the medical necessity of benefits or services under dispute.

   1. (a) The committee's recommendation is not binding but may be admitted as evidence and included in the hearing record.
   2. (b) If a party to the proceeding objects to the committee's determination, a representative of the committee shall be available at the hearing for examination by the presiding officer and each party.
4. (4) The presiding officer may require any party to submit a prehearing position statement setting forth that party's positions.
5. (5) A party may enter into a written stipulation during the preliminary conference or at any time during the process.

6. (6) Ex parte communication with the presiding officer is prohibited.

   1. (a) If a party attempts ex parte communication, the presiding officer shall inform the offeror that any communication the presiding officer receives off the record will become part of the record and furnished to every party.
   2. (b) Ex parte communication does not apply to communication on the status of the hearing and uncontested procedural matters.
7. (7) The agency shall allow the aggrieved person or a representative to examine each DIH document and record upon written request to DIH at least three days before the hearing.

8. (8) A party may request access to protected health information in accordance with Rule R380-250, which implements the privacy rule under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

   1. (a)(i) The agency may request copies of pertinent records in the possession of a party and the member's health care providers.

      1. (ii) In the event the member or provider fails to produce the records within a reasonable time, DIH may review each pertinent record in the custody of the member or provider during regular working hours at least three days after issuing written notice.

   2. (b) The member shall submit necessary medical records with the hearing request when possible, including:

      1. (i) the provision of each service and activity addressed in the hearing request;
      2. (ii) the first and last name of the party;
      3. (iii) the reason for performing the service or activity that includes the party's complaint or symptom;
      4. (iv) the member's medical history;
      5. (v) examination findings;
      6. (vi) diagnostic test results;
      7. (vii) the goal or need the plan of care identifies; and
      8. (viii) the observer's assessment, clinical impression, or diagnosis that includes the date of observation and identity of the observer.

   3. (c) The necessary medical records shall demonstrate that the service is:

      1. (i) medically necessary;
      2. (ii) consistent with the diagnosis of the member's condition; and
      3. (iii) consistent with professionally recognized standards of care.

9. (9) The presiding officer may require each party to file a signed prehearing disclosure form at least ten calendar days before the scheduled hearing that identifies:

   1. (a) fact witnesses;
   2. (b) expert witnesses; and
   3. (c) any exhibits and reports each party intends to offer into evidence at the hearing.
10. (10) Each party shall supplement the disclosure form with information that becomes available after filing the original form.

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