Fair Hearing Review Process
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Governs fair hearing rights and procedures for practitioners affected by certain adverse Credentials Committee actions related to quality of care, competence, or professional conduct within Care Continuum (NHP/NHIC/NH TPA/NHAS). Applies to practitioners whose participation/agreements are restricted, suspended, terminated, or non‑renewed for those reasons.
No material clinical or coverage changes in this revision.
Fair Hearing Eligibility
Fair Hearing Eligibility and Exclusions
Adverse decisions that constitute grounds for fair hearing review
ALL of the following
Grounds for fair hearing (any of the following):
- Restriction or suspension of the practitioner’s participation as an NHP/NHIC/NH TPA/NHAS practitioner for more than 30 calendar days
- Termination of the practitioner’s participation as an NHP/NHIC/NH TPA/NHAS practitioner
- Termination or non-renewal of a practitioner’s Provider Agreement when taken for reasons of the practitioner’s quality of care, competence, or professional conduct
Exclusions and alternative process
- Denial of an applicant’s initial credentialing application is NOT grounds for a fair hearing under this policy; instead, the practitioner may file a written request for reconsideration within 30 calendar days of receiving notice of denial
- Termination or non-renewal of participation or Provider Agreement for reasons other than quality of care, competence, or professional conduct does NOT qualify for a fair hearing under this policy
Right to request hearing
- When a practitioner receives notice of an adverse decision by the Credentials Committee that meets the grounds above, the practitioner may request a fair hearing before a Hearing Committee
Grounds for Fair Hearing and Reconsideration / Required Documentation
Grounds for Fair Hearing and Reconsideration
The following adverse Credentials Committee decisions (only if taken for reasons of a practitioners quality of care, competence, or professional conduct) qualify for a fair hearing: restriction or suspension of participation for more than 30 calendar days; termination of participation as an NHP/NHIC/NH TPA/NHAS practitioner; and termination or non‑renewal of a practitioner's Provider Agreement. Denial of an initial application is not grounds for a fair hearing; instead the practitioner may file a written request for reconsideration within thirty (30) calendar days of receiving notice. Termination or non‑renewal for reasons other than quality, competence, or professional conduct also do not qualify for fair hearing under this policy. Practitioners who receive notice of a qualifying adverse decision may request a fair hearing before a Hearing Committee.
- Qualifying actions: restriction/suspension >30 calendar days; termination of participation; termination or non‑renewal of Provider Agreement (when based on quality/competence/professional conduct).
- Initial credentialing denial is excluded; practitioner may request reconsideration within 30 calendar days of notice.
- Non‑renewal/termination for reasons other than quality, competence, or professional conduct are excluded.
- Practitioner may request a fair hearing upon receipt of qualifying adverse decision.
Documentation and Procedural Notice Requirements for Hearing Requests
The Medical Director or Designated Physician must give written notice by email within ten (10) calendar days of an adverse Credentials Committee decision to any practitioner entitled to a fair hearing. The notice must advise the practitioner of the decision and basis, their right to request a fair hearing within thirty (30) calendar days, and details about hearing scheduling, representation, evidence, and post‑hearing report.
- Notice delivered within ten (10) calendar days by Medical Director or Designated Physician via email.
- Notice must: state the decision/action and basis; advise right to request a fair hearing within 30 calendar days; explain that failure to request within 30 days or to appear waives the right.
- Notice must state hearing date will be no less than 30 and no more than 60 calendar days after receipt of request (unless practitioner requests earlier date).
- Practitioner may request copies of all material considered; must include name, address, phone (and occupation if representative is not an attorney) of any representative in the request.
- Notice must advise rights to be represented, call/examine/cross‑examine witnesses, present evidence, submit a written statement, and that the practitioner will receive the Hearing Committee's written report and recommendation upon completion.
Codes and Billing References
| No codes listed |
Definitions and Policy Ownership
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