360-10.17 Appeals to the commissioner; responsibilities and rights in the appeal process.

    (a) An MA recipient who is excluded from participation in an MCP; a participant who is required to withdraw from an MCP; or a participant whose request for an exemption from participation, a change of managed care provider or medical services provider, or withdrawal for good cause has been denied by the social services district may file a written appeal to the commissioner within five days of the receipt of the notice of the final determination by the recipient. Such appeal must include the following information:

        (1) the name and address of the person making the appeal and the date the person received the social services district's determination;

        (2) a description of the circumstances which constitute good cause, if applicable, or an explanation why the social services district's determination should be reversed;

        (3) the date the original request was filed with the social services district or managed care provider, if applicable;

        (4) a copy of the determination made by the managed care provider, if applicable;

        (5) a copy of the notice of determination issued by the social services district; and

        (6) any other relevant information or documentation.

    (b) Appeals to the commissioner must be decided within 10 days of receipt of the appeal. A written decision will be issued that either directs the social services district to reverse its decision or affirms the denial of the request. The commissioner's decision will explain the reason(s) for the decision, state the facts upon which the decision is based and cite relevant statutory or regulatory authority for the determination.

    (c) An appeal to the commissioner made under this section is not a fair hearing described in Part 358 of this Title. The commissioner will designate an appeals officer who must decide all appeals from denials made by the social services districts. A decision of the appeals officer may be appealed pursuant to Article 78 of the Civil Practice Law and Rules.

    (d) Timeliness of determination. The participant's request and all appeals must be decided so that a determination can be implemented no later than the first day of the second month after the month the participant's initial request was made. If a final determination is not timely made, the participant's request will be deemed to have been approved as of the date upon which a final determination should have been made.

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