Section 610.012 - General Description of the Fair Hearing Process(A) The fair hearing process is an administrative, adjudicatory proceeding where dissatisfied applicants, members, and nursing facility residents can, upon written request, obtain an administrative determination of the appropriateness of (1) certain actions or inactions by the MassHealth agency;(2) certain actions or inactions by a managed care contractor;(3) actions to recover payment for benefits to which the member was not entitled at the time the benefit was received;(4) alleged coercive or otherwise improper conduct by a MassHealth agency employee;(5) a notice of intent or failure to give notice of intent by a nursing facility to discharge, transfer, or readmit a resident; or(6) a PASRR determination.(B) The hearing process is designed to secure and protect the interests of both the appellant and, as appropriate, the MassHealth agency or its personnel and to ensure equitable treatment for all involved.(C) A hearing is conducted by an impartial hearing officer of BOH.(1) The decision of the hearing officer is based only on those matters that are presented at the hearing or during a record open period.(2) The hearing officer examines the facts, the applicable law, the MassHealth agency's rules, regulations, contracts, and Policy Memoranda, and the other circumstances of the appeal presented by the parties to determine the legality and appropriateness of the MassHealth agency's or MassHealth agency employee's action, or the action of a managed care contractor or nursing facility.(3) The hearing officer is impartial in that he or she(a) attempts to secure equitable treatment for the parties;(b) has had no prior involvement in any matter over which he or she conducts a hearing, except in a capacity as a hearing officer; and(c) has had no direct or indirect financial interest, personal involvement, or bias pertaining to such matter. (D) The final hearing decision is binding upon all parties to the hearing, except that appeals may be subject to review under the rehearing process described in 130 CMR 610.091. In the case of a decision about an appeal by an ICO or a SCO enrollee concerning the amount, duration, or scope of covered benefits, where both the BOH and the IRE issue a decision, the ICO or SCO is bound by both decisions and will provide the services that are closest to the enrollee's requested relief in the appeal.(E) Appeals involving transfers, discharges, or failure to readmit initiated by nursing facilities are binding only on the facility and the resident.(F) Appeals involving PASRR determinations are binding on DMH and DDS.(G) Final decisions of the hearing officer are subject to judicial review in accordance with 130 CMR 610.092.(H) Final decisions of the IRE are subject to administrative review and judicial review in accordance with federal law.(I) An ICO is bound by decisions as referenced in 130 CMR 610.012(G) and (H).Amended by Mass Register Issue 1354, eff. 12/18/2017.Amended by Mass Register Issue 1397, eff. 8/9/2019.Amended by Mass Register Issue 1485, eff. 12/23/2022.