Sec. 10.01.04.08. Findings, Timing of Decision, and Effect of Decision

A. Findings.

(1) The administrative law judge shall:

(a) Prepare a written summary of findings and conclusions based exclusively on the record; and

(b) Make a decision based on his findings and conclusions.

(2) The summary of findings and conclusions shall:

(a) State the evidence, policies, regulations, or laws upon which the administrative law judge's decision is based; and

(b) Provide written notice to the appellant that, if they are not satisfied with the decision, they may seek additional appeals as specified in §C of this regulation.

B. Timing of Hearing Decision.

(1) If the appellant is not enrolled in an MCO, the administrative law judge shall forward to the appellant a copy of the findings, conclusions, and decision within 90 days from the earlier of the following:

(a) The date the appellant postmarked, delivered in person, or sent by email or facsimile to the Office of Health Services a request for a fair hearing pursuant to Regulation .04D(1) of this chapter;

(b) The date the appellant postmarked, delivered in person, or sent by facsimile to the Office of Administrative Hearings or the delegate agency a request for a fair hearing pursuant to Regulation .04D(2) of this chapter;

(c) The date the appellant emailed, postmarked or delivered in person to the Maryland Health Benefit Exchange a request for a fair hearing pursuant to Regulation .04D(2) of this chapter; or

(d) The date the appellant called or sent by facsimile to the Consolidated Services Center a request for a fair hearing pursuant to Regulation .04D(2) of this chapter.

(2) If the appellant is enrolled in an MCO, the administrative law judge shall forward to the appellant or the appellant’s authorized representative a copy of the findings, conclusions, and decision within:

(a) 3 working days after the Office of Administrative Hearings receives the fair hearing request if the appeal concerns the medical necessity of a denied benefit or service, and the hearing that meets the criteria, as determined by the Department, for an expedited hearing as provided in Regulation .04A(3)(b)(ii) of this chapter; or

(b) 30 days of the hearing if the appeal does not concern the medical necessity of a denied benefit or service.

(3) If the date of the fair hearing is postponed at the appellant's request, the length of the postponement may not be counted as part of any of the time periods specified in §B(1) or (2) of this regulation.

C. Appeal Rights.

(1) Any party may seek administrative review of the administrative law judge’s decision as provided in Health-General Article, §§2-206 and 2-207, Annotated Code of Maryland, and subsequent judicial review as provided in State Government Article, §10-215, Annotated Code of Maryland, except if the appeal is solely of a decision of the Maryland Health Benefit Exchange, in which case any party may seek judicial review as provided in State Government Article, §10-215, Annotated Code of Maryland.

(2) An administrative law judge’s decision adverse to the appellant shall be implemented immediately.

(3) To the extent an administrative law judge’s decision upholds the determination of the Maryland Health Benefit Exchange with respect to an applicant for an insurance affordability program described in Regulation .01B(9)(a)-(e), the applicant may appeal to the United States Department of Health and Human Services.

D. Effect of Decision.

(1) When the decision requires action by the delegate agency, that agency shall notify the Program of its compliance with the decision.

(2) When the decision is favorable to the appellant, or when the Department, Program, or delegate agency grants the appellant the relief the appellant requests before the decision, the Department, Program, or delegate agency, where applicable, shall:

(a) Authorize corrected payments or relief retroactive to the date the incorrect action was taken; and

(b) If appropriate, provide for admission or readmission of the appellant to a facility.

(3) Any payment or action by the Department, Program, or delegate agency in §D(2) of this regulation may not constitute a waiver of the Department’s, Program’s or delegate agency’s sovereign immunity from suit.

(4) When the decision is favorable to the appellant and is an MCO service, the MCO shall authorize or provide the disputed services no later than 72 hours from the date it receives notice reversing the MCO’s determination.