プロバイダーマニュアル

公正な審問プロセス

プロバイダーは、能力または専門的行動に関連する問題に基づいて、PAC が資格証明、再資格証明を拒否するか、制裁を発行するか、ネットワークからプロバイダーを終了する場合、第 2 レベルの上訴である公正な審問を要求することができます。公聴会の要請は、PAC の通知日から 30 日以内に行う必要があります。プロバイダーは、公正な聴聞会の場所、時間、日付についての書面による通知を受け取ります。この日付は、プロバイダーから上訴の要求を受け取った日から 30 日以内でなければなりません。

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.