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New York Codes, Rules and Regulations (NYCRR)

Title 9 Part 9720

Executive Department

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8 sections

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9 NYCRR 9720.1 - Introduction

Source version current through May 15, 2022

Later State Register activity may affect this section.

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NYCRR title agency
Executive Department
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Section source receipt
Source version current through
May 15, 2022

The rights and obligations of applicants and participants with respect to the fair hearing process are governed by this Part.

9 NYCRR 9720.2 - Right to a fair hearing

Source version current through May 15, 2022

Later State Register activity may affect this section.

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NYCRR title agency
Executive Department
Section status
Section source receipt
Source version current through
May 15, 2022
(a)Applicants and participants shall be entitled to a fair hearing to have a contractor's determination after reconsideration reviewed on the following grounds:
(1)denial of benefits;
(2)failure to determine the applicant's eligibility or, if found eligible, failure to issue a card or authorize services within three days from the date the applicant met his/her registration fee, premium or deductible requirement;
(3)discontinuance or suspension of coverage, in whole or in part;
(4)computation of his/her cost-sharing responsibilities;
(5)any other grounds affecting the applicant or participant's coverage, including a determination of the receipt of medical assistance or equivalent or better public or private insurance benefits.
(b)Notwithstanding the above, participants have no right to a hearing when the contractor discontinues payment to a provider or the panel authorizes a mass change.

9 NYCRR 9720.3 - Information concerning the right to a fair hearing

Source version current through May 15, 2022

Later State Register activity may affect this section.

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Dates and status
NYCRR title agency
Executive Department
Section status
Section source receipt
Source version current through
May 15, 2022

Every applicant and participant has the right to receive certain information in writing when the contractor issues a written determination after reconsideration which affects the applicant's/participant's coverage. Each applicant and participant has the right to a notice which advises:

(a)of his/her right to a State fair hearing;
(b)of the method by which he/she may obtain a hearing;
(c)that he/she may be represented by legal counsel, or by a relative, friend or other spokesman, or he/she may represent himself/herself;
(d)of the community legal services and senior citizen services available to assist him/her in the reconsideration or fair hearing; and
(e)of the types of information he/she may submit at the hearing.

9 NYCRR 9720.4 - Notice of determination after reconsideration

Later State Register activity may affect this section.

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Dates and status
NYCRR title agency
Executive Department
Section status
Section source receipt
(a)After having reviewed an action, or failure to act, which denied, discontinued, suspended or reduced coverage pursuant to the mandatory reconsideration process provided for in Part 9630 of this Title, the contractor shall issue a written notice of determination after reconsideration to the applicant or participant requesting the reconsideration.
(b)The notice shall be issued within three days of the determination and mailed to the applicant's/participant's designated address.
(c)The notice shall clearly state the determination made, the basis and specific reasons for the determination, the action to be taken and the effective date of the action, and shall include information concerning the right to a fair hearing.

9 NYCRR 9720.5 - Rights in fair hearing process

Source version current through May 15, 2022

Later State Register activity may affect this section.

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Dates and status
NYCRR title agency
Executive Department
Section status
Section source receipt
Source version current through
May 15, 2022

When an applicant or participant requests a fair hearing, he/she becomes the appellant and has the right to:

(a)examine his/her file and receive copies of documents in the file needed to prepare for the fair hearing;
(b)examine and receive copies of all documents and records which will be submitted into evidence at the fair hearing by the contractor;
(c)reschedule the hearing (adjournment);
(d)be represented by an attorney or other representative or to represent himself/herself;
(e)have an interpreter, at no charge, if he/she does not speak English or is deaf (the appellant must advise the department prior to the hearing if an interpreter will be needed); and
(f)have witnesses present written and oral evidence to explain why action taken was wrong.

9 NYCRR 9720.6 - Request for a fair hearing

Source version current through May 15, 2022

Later State Register activity may affect this section.

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Dates and status
NYCRR title agency
Executive Department
Section status
Section source receipt
Source version current through
May 15, 2022
(a)Any clear communication to the department by or on behalf of an applicant or participant requesting review of a contractor's determination after a reconsideration shall constitute a request for a fair hearing if made within 60 days of the written determination after reconsideration.
(b)A fair hearing may be requested in writing, by telephone or in person.
(1)Telephone requests should be made to the toll-free telephone number specified by the contractor in the notice of determination after reconsideration.
(2)Written requests should be made to the department by writing:

Fair Hearing Section

EPIC

P.O. Box 1930

Albany, NY 12201

9 NYCRR 9720.7 - Examination of file prior to hearing

Source version current through May 15, 2022

Later State Register activity may affect this section.

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Dates and status
NYCRR title agency
Executive Department
Section status
Section source receipt
Source version current through
May 15, 2022
(a)If copies of the documentary evidence which the contractor plans to use at the hearing have not already been provided to the appellant or his/her representative, an opportunity to examine such documents, if requested, shall be afforded the appellant or his representative at a reasonable time before the date of the hearing.
(b)The appellant or the representative shall be afforded an opportunity to examine the entire case file at a reasonable time before the hearing and to make copies of any documents contained in the file without charge.

9 NYCRR 9720.8 - Authorization of representative

Source version current through May 15, 2022

Later State Register activity may affect this section.

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Dates and status
NYCRR title agency
Executive Department
Section status
Section source receipt
Source version current through
May 15, 2022

An individual or organization, other than an attorney, representing an appellant must have a written authorization, unless the condition of the appellant makes it impracticable for him to execute one.

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