Guam § 2915 - Appeals and Grievance Process.

§ 2915. Appeals and Grievance Process.

(a) The Director, in consultation with the Administrator, shall establish, subject to the Administrative

Adjudication Law and the provisions of this Article, a grievance and appeal procedure to cover grievances

arising pursuant to this Article. The grievance and appeal procedure shall include time limits for filing

appeals or grievances, and shall establish procedures to conduct fair hearings to be used by Providers, Non-

Providers, eligible persons, persons applying to be Providers or persons denied eligibility. A grievance for

the denial of a claim for reimbursement for services, or for denial of eligibility, may contest the validity of

any adverse action, decision, policy implementation, or rule that related to or resulted in the full or partial

denial of the claim. The grievance and appeal procedure shall contain provisions related to the notice to be

provided to aggrieved parties, including notification of final decisions, complaint processes and internal

appeals mechanisms. Any grievance and appeal procedure not specified pursuant to this Subsection, but

identified pursuant to this Subsection, shall be handled in the same manner. Other provisions for processing

grievances shall include:

(1) the client has a right to have another person of that client’s own choosing to assist with that

client’s case; and

(2) if the client chooses to go through a hearing, an opportunity will be granted for a hearing

conducted by an impartial hearing officer.

(3) Notification of Time and Place of Hearing. The time, date and place of the hearing shall be

arranged to provide the claimant and all other parties involved at least ten (10) working days of advance

written notice. Notice shall:

(A) inform claimant of the time, date and place of the hearing;

(B) advise the claimant or representative of the name, address and phone number of the

person to notify in the event it is not possible for the claimant to attend the scheduled hearing;

(C) specify that the agency will dismiss the hearing request if the claimant or the claimant’s

representative fails to appear for the hearing without good cause;

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(D) explain that the claimant or the claimant’s representative may examine the case file prior

to the hearing; and

(E) advise the claimant of the possible availability of legal services from the Public Defender

Service Corporation.

(4) Hearing Officer. hearing shall be conducted by an attorney or an arbitrator who does not have

any personal stake or involvement in the case; and was not directly involved in the initial determination

of the action which is being contested. Responsibilities of the hearing officer shall include:

(A) administer required oaths or affirmations;

(B) insure all relevant issues are considered;

(C) request, receive and make part of record all evidence determined necessary to decide the

issues being raised; and

(D) regulate the conduct and course of the hearing, consistent with due process to insure an

orderly hearing.

(5) Hearing Decisions. The claimant shall be notified in writing of the decision and the reasons

for the decision.

(6) After a hearing decision, which upholds the agency action, the claimant shall be notified of

the right to pursue judicial review of the decision.

(b) A grievance or appeal shall be filed in writing and received by the Administrator no later than sixty

(60) days after the date of the adverse action, decision or policy implementation being grieved. If a

grievance or appeal is not filed within the time required by this Section, the initial decision shall be

considered the final decision.

(c) [No text]

(1) The Hearing Officer shall render a decision on each grievance no later than ninety (90) days

from the date the Administrator receives the request for a hearing, unless the hearing is postponed or

rescheduled at the request of all of the parties, or the hearing officer orders a further extension.

(2) If a person is dissatisfied with a final decision on a grievance properly submitted and heard

under the provisions of this Article, the person may file for judicial review under the provisions of the

Administrative Adjudication Law.

(d) Notice of Change in Benefits. Notice of a denial or discontinuance shall be made in writing to the

client ten (10) days in advance, and state the reason and effective date.