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expressly waives its rights to an internal review of a | | grievance or an appeal, the enrollee and the provider involved | | are relieved of any obligation to complete the grievance or | | appeal and may, at the enrollee's or the provider's option, | | seek further appeal through an applicable external appeals | | process. |
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| | | Sec. 16. 24-A MRSA §4303, sub-§5 is enacted to read: |
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| | | 5.__External appeals.__The following provisions apply to | | external appeals. |
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| | | A.__The bureau shall provide for a fair hearing that meets | | the requirements of this subsection for the review of an | | externally appealable decision. The expenses incurred by the | | bureau in connection with a hearing must be paid by the | | carrier.__The bureau may contract with other state agencies | | performing administrative fair hearings to provide the | | hearing in accordance with the requirements of this | | subsection. |
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| | | B.__A carrier may condition the use of the external appeals | | process hearing upon completion of the internal review | | process, but only if the internal review decision is made on | | a timely basis consistent with the deadlines imposed by | | bureau rules. |
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| | | C. The external appeals process hearing must be conducted | | consistent with standards established by the superintendent | | in accordance with Title 5, chapter 375, subchapter IV and | | the following. |
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| | | (1) The hearing must provide for a fair, de novo | | determination. |
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| | | (2)__As part of the hearing, the hearing officer shall | | determine whether a decision is an externally | | appealable decision, including: |
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| | | (a)__Whether the decision involves an expedited | | appeal; |
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| | | (b)__Whether appropriate deadlines for the | | internal review process were established based on | | medical exigencies; and |
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| | | (c)__Whether the internal review process has been | | completed. |
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