CMO failed to properly raise issue of provider’s untimely hearing request

Topic: Care Management Organization, Decided by: Judge Schroer 
Docket Number: 2300240 , Decision Date: April 21, 2023 
Attachment: Click here to download the decision. 

The first matter at hand in this case was whether a health care provider could bring this case to the Court despite its untimely appeal of a refusal by a care management organization (CMO) to pay for certain charges of healthcare services. The Court concluded that the hearing could proceed, as the CMO did not properly raise the timeliness issue under either the Administrative Rules of Procedure or the Judge’s prehearing orders. The Court ultimately ruled in favor of the provider, finding that the CMO breached the parties’ agreement by unilaterally removing disallowed charges and reducing payments.

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