SECTIONS 12693.85-12693.89 - California Statutes

INSURANCE CODE

SECTION 12693.85-12693.89

12693.85. Program decisions described in this section may be
appealed to the board. If an applicant believes that a written
decision on one of the following specified issues was made in
violation of the program statutes or regulations, or other written
representation of program policy made to the individual by the
program or the board, that individual may file an appeal with the
board. Decisions that may be appealed are the following:
(a) A decision that a child is not qualified to participate or
continue to participate in the program.
(b) A decision that a child is not eligible for enrollment or
continuing enrollment in the program.
(c) A decision as to the effective date of coverage.

12693.86. (a) An appeal shall be filed in writing with the
executive director within 60 calendar days of the date of the notice
of the decision being appealed.
(b) An appeal shall include all of the following:
(1) A copy of any decision being appealed, or a written statement
of the action or failure to act being appealed.
(2) A statement specifically describing the issues that are
disputed by the appellant.
(3) A statement specifically describing the program statute or
regulation, or other written representation of program policy that
the appellant believes the program or board violated.
(4) A statement of the resolution requested by the appellant.
(5) Any other relevant information the appellant wants to include.
(c) Any appeal that does not specifically allege a violation of a
program statute or regulation, or other written representation of
program policy will be deemed to be a request for program review
pursuant to Section 12693.88.
(d) An appeal that specifically alleges a violation of program
statute or regulation or other written representation of program
policy, but fails to include any other necessary information, shall
be returned to the appellant without review. The appellant may
resubmit the appeal. The resubmittal shall be filed within the time
limits of subdivision (a) or within 20 calendar days of the receipt
of the returned appeal, whichever is later.

12693.87. (a) Any appellant who files an appeal pursuant to Section
12693.85 shall receive an initial administrative review of the
appeal.
(b) Administrative reviews of appeals shall be conducted in two
steps. Each appeal will be reviewed by the program to determine if
the requested resolution is required by the statutes and regulations
governing the program, or required in order to be consistent with a
written representation of program policy made by the program or the
board. If so, the appropriate action will be taken within 30 days of
the receipt of the appeal, and the appellant will be notified. If
not, the appellant will be so notified within 30 days of the receipt
of the appeal and informed that he or she may request review by the
executive director. This request must be filed in writing with the
executive director within 30 days of the date of the notice of the
program determination and shall include the information specified in
subdivision (b) of Section 12693.86.
(c) In conducting an administrative review of an appeal, the
executive director may contact the appellant and any other party for
further information.
(d) The executive director's decision shall be in writing.
(e) The appellant retains the right to request an administrative
hearing if the appellant is not satisfied with the decision of the
executive director. Such a request shall be filed within 30 calendar
days of receipt of the executive director's decision. It shall
include a clear and concise statement of what action is being
appealed, and the reasons the executive director's decision is not
correct.

12693.88. In addition to the appeal process established above, the
board shall establish a program review process. If a subscriber or
purchasing credit member is not eligible to file an appeal pursuant
to Section 12693.85, but wants to have any program decision reviewed,
he or she may request that the program review the decision. A review
pursuant to this section is separate from and independent of an
appeal pursuant to Section 12693.85, and a person that files a
request pursuant to this section shall not, thereby, gain any right
of appeal. Pursuant to Section 12693.49, any dissatisfaction with an
action of a participating health, vision, or dental plan shall be
resolved with the plan rather than by requesting program review. When
an appeal that requests an administrative hearing is received, the
appeal shall be set for hearing as provided in Section 12693.89.

12693.89. (a) Administrative hearings of appeals shall be conducted
according to the appeal procedures, including pre- and post-hearing
procedures, set forth in Article 3 (commencing with Section 1140) of
Chapter 2 of Division 2 of Title 1 of the California Code of
Regulations. Article 3 (commencing with Section 1140) is hereby
incorporated by reference, subject to the following modifications:
(1) Reference to the Health and Welfare Agency or the component
department shall be deemed reference to the Managed Risk Medical
Insurance Board.
(2) Reference to the private nonprofit human service organization
shall be deemed reference to the appellant.
(3) Reference to Health and Safety Code sections providing the
bases, grounds, authorization, or procedures for appeals shall be
deemed reference to the bases and authorization, for appeal found in
Section 12693.85 and the appeal procedures found in this section.
(4) The 30-day time period specified in subdivision (b) of Section
1140 of Title 1 of the California Code of Regulations shall be
extended to 60 days, and the 10-day time period in subdivision (a) of
Section 1141 of Title 1 of the California Code of Regulations shall
be extended to 30 days.
(5) If the proposed decision submitted to the board is not adopted
as the decision, the board may itself decide the case on the record,
or may refer the case to the same hearing officer to take additional
evidence. If the case is referred back to the hearing officer, the
hearing officer shall prepare a new proposed decision based on the
additional evidence and the record of the prior hearing.
(6) The decision of the board shall be issued within 90 days
following the initial hearing or, if the case is referred back to the
hearing officer, within 90 days of the second hearing.
(b) The board may elect to have a hearing conducted by an
Administrative Law Judge employed by the Office of Administrative
Hearings pursuant to the provisions of Chapter 5 (commencing with
Section 11500) of Part 1 of Division 3 of Title 2 of the Government
Code.