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(a) Except as provided in (b) of this section, if an enrollee is not satisfied with the decision of the plan administrator under 2 AAC 39.520(c) , the enrollee may appeal to the board within 30 days after receiving the plan administrator's decision. Unless the recipient requests a hearing directly before the board at the time of the appeal, the secretary of the board shall appoint a qualified hearing officer to hear the appeal.
(b) Determinations of the plan administrator respecting issues relating to coordination of benefits and the calculation of usual, customary and reasonable charges are not appealable to the board.
(c) Appeals to the board are subject to the procedures set out in 2 AAC 35.160, except that a party to the appeal may be represented by counsel only if the party gives written notice to the board secretary (for appeals before the full board) or the hearing officer (for appeals before a hearing officer), with service upon the other party, at least 30 days before the scheduled hearing date.
(d) If a hearing is held before a hearing officer, that officer shall issue a recommended decision within 21 days of the completion of the hearing or, if the record is held open following completion of the hearing for submission of argument or additional evidence, within 21 days of the date that the record is closed. The recommended decision shall be presented to the board at its next scheduled meeting. The board will, if requested, allow either party to speak to the proposed decision. The board may adopt the recommended decision in whole, may adopt the recommended decision with modifications, or may reject the recommended decision. The board will, in its discretion, decide the appeal upon the record including the transcript or tape recording of the earlier hearing, with or without taking additional evidence, or may refer the appeal to the same or another hearing officer to take additional evidence.
(e) If the appeal is referred to a hearing officer for the taking of additional evidence under (d) of this section, the hearing officer shall prepare a proposed decision based upon the additional evidence and the record of the earlier hearing.
(f) The board will, in its discretion, give the parties the opportunity to present argument, either oral or written, before the board.
(g) The time limits established in this section may be extended if it is determined that the limits impose undue restrictions on either party.
History: Eff. 5/28/99, Register 151
Authority: AS 39.35.040
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Last modified 7/05/2006