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(1) A third party administrator must have a written procedure, approved in writing by the department before implementation, for resolution of grievances or complaints brought by enrollees or their parents or guardians either individually or as a class. In a situation requiring urgent care or emergency care, the department may require the third party administrator to expedite resolution of a grievance within a time line established by the department.

(2) Except when the HMK coverage group eligibility has been denied, an enrollee, parent, or guardian must exhaust the third party administrator's grievance procedure before appeal of the matter may be made to the department.

(3) An applicant, parent, or guardian aggrieved by a denial, suspension, or termination of the HMK coverage group eligibility or an enrollee, parent, or guardian aggrieved by a final grievance decision of a third party administrator, including but not limited to a reduction or denial of benefits, may request a fair hearing in accordance with ARM 37.5.304, 37.5.307, 37.5.313, 37.5.322, 37.5.325, 37.5.328, 37.5.331, 37.5.334, and 37.5.337.

(4) If a written request for hearing is not received by the department within 90 days after the date a notice of adverse action is mailed by the department or a final grievance decision is mailed by a third party administrator, the hearing officer may deny a hearing as provided in ARM 37.5.313.

(5) Continuation of HMK benefits during an appeal process will be applied as specified in ARM 37.5.316(3) through (15).

History: 53-4-1009, MCA; IMP, 53-4-1003, MCA; NEW, 2000 MAR p. 1221, Eff. 5/12/00; AMD, 2004 MAR p. 330, Eff. 2/13/04; AMD, 2008 MAR p. 49, Eff. 1/18/08; AMD, 2009 MAR p. 1673, Eff. 10/1/09; AMD, 2010 MAR p. 2217, Eff. 10/1/10; AMD, 2013 MAR p. 214, Eff. 2/15/13.

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