Manuale del fornitore


Providers may request a second level of appeal, Fair Hearing, when the PAC denies credentialing, recredentialing, issues a sanction or terminates a provider from the network based on issues related to competence or professional conduct. A request for a Fair Hearing must be made within 30 days of the date of the PAC’s notification. The provider will receive written notice of the place, time and date of the Fair Hearing, which date shall not be less than 30 days after the date the request for appeal is received from the provider.

Additionally, the provider will receive an explanation of the hearing procedures, and a list of witnesses, if any, expected to testify on behalf of Carelon. The Chair of the PAC will identify peer reviewers who will participate as the Fair Hearing Panel, assuring representation of the discipline of the practitioner requesting the appeal. These peers will not have any economic interest adverse to provider, nor will they have participated in the decisions of the PAC or NCC. One member of the Fair Hearing Panel will be selected to act as the hearing officer and will preside over the Fair Hearing. Both Carelon and the provider will make reasonable efforts to establish a mutually agreed upon date for the hearing. Both Carelon and the provider have the right to legal representation at the Fair Hearing. The provider will receive a written recommendation from the panel within 15 business days after the Fair Hearing. The Fair Hearing process as set forth above is subject to applicable state and federal law.