Sec.17a-453a-18. Appeals and fair hearings

There are two (2) types of appeals that an individual may file with DMHAS or its designated agent:

(a) First-level appeal.

(1) A first-level appeal may be filed by the individual or his or her authorized representative. The first-level appeal shall be filed with the designated agent not later than seven (7) calendar days after the decision by the designated agent to deny, reduce or terminate covered behavioral health services, unless good cause is shown for late filing as determined by the designated agent. A first-level appeal is not a "contested case" pursuant to section 4-166(2) of the Connecticut General Statutes.

(2) A first-level appeal shall be filed in writing with all supporting records. All records relating to a first-level appeal shall be kept confidential, unless disclosure is otherwise required by law or authorized in writing by the individual.

(3) DMHAS or its designated agent shall send written notice of the first-level appeal decision by the designated agent to the individual or his or her authorized representative and to the contracted provider not later than seven (7) calendar days after the designated agent has determined it has received all information necessary to render a decision.

(4) If the designated agent fails to issue a decision within seven (7) calendar days, the individual or his or her authorized representative may treat it as a denial and request further review under the second-level appeal.

(b) Second-level appeal.

(1) The individual or his or her authorized representative may file a second-level appeal of a first-level appeal decision that denies, reduces or terminates covered behavioral health services. The second-level appeal shall be filed with DMHAS not later than seven (7) calendar days after the first-level appeal decision, unless good cause is shown for a late filing, as determined by DMHAS. A second-level appeal is not a "contested case" within the meaning of section 4-166(2) of the Connecticut General Statutes.

(2) The second-level appeal shall be filed in writing with all supporting records. All records relating to the second-level appeal shall be kept confidential, unless disclosure is otherwise required by law or authorized in writing by the individual.

(3) The individual or his or her authorized representative and the contracted provider shall be sent written notice of the second-level appeal decision of DMHAS not later than seven (7) calendar days after DMHAS has determined it has received all information necessary to render a decision.

(4) DMHAS shall neither accept nor review a written second-level appeal if a first-level appeal submitted to the designated agent is still being reviewed within the time period permitted by this section.

(5) DMHAS shall notify the contracted provider and the individual or his or her authorized representative of its second-level appeal decision not later than seven (7) business days after DMHAS determines it has received all information necessary to render a decision.

(c) Fair Hearing. Any individual who requested covered behavioral health services from the designated agent and had the covered behavioral health services denied or, if delivered, reduced or terminated without the individual's consent and who has received an unfavorable second-level appeal from DMHAS, may request a fair hearing. The process for such a hearing shall be the same as specified in sections 17a-451 (t)-1 to 17a-451 (t)-15, inclusive, of the Regulations of Connecticut State Agencies.

(Adopted effective December 7, 2009)