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Zenith -- Provider Appeal for Network Exclusion Policy

  • 4.

    Provider relations will give the information packet to the PEC Chair. The PEC Chair will appoint an appropriate panel for the hearing review.

  • 5.

    Any Zenith Medical Director that participated in the decision to Exclude the Provider may not participate as a voting member of the PEC appeal hearing panel. Other Zenith Medical Directors who were not involved in the prior Exclusion decision are eligible to participate as voting members.

  • 6.

    The hearing will be scheduled within 30 business days of the appointment of the panel by the PEC Chair.

  • 7.

    The Excluded Provider will receive written notice from the Provider Relations Department of the date and time of the PEC hearing. The notice will include the names and position of the members of the PEC review panel.

  • 8.

    The PEC hearing will consider all newly submitted and historical information.

  • 9.

    Within ten business days of the hearing, the PEC Chair will provide the Provider

Relations Department the PEC’s written determination. supported by a majority vote of the PEC members.

The determination must be

  • 10.

    Within 2 business days of receiving the written determination, the Provider Relations Department shall record the determination and send the determination to the Excluded Provider with a copy to the presenting Medical Director.

  • 11.

    All information obtained and exchanged as part of this process is confidential.

12. The Provider Relations Department shall take all actions necessary to effectuate the final determination.

Presentation of Evidence Before and During Hearing

Hearings will not follow the Court Rules of Evidence but will be conducted in an informal

manner.

At least 5 business days prior to the date of hearing, both Zenith and the Provider will

be expected to share issue lists, summary arguments and any evidence or materials to be relied upon at the hearing. If either the Provider or Zenith expects to request a witness to appear at the hearing, the name, occupation and a summary of the expected testimony of that witness must be provided to the other party and the PEC Chair at least 5 business days prior to the date

of the hearing. This requirement does not include the Provider or the designated presenter for Zenith. The PEC Chair is responsible for assuring that all panel members are provided

information an attorney hearing the

necessary for review of the file and prepare for the hearing. If the Provider will have at the hearing, the Provider must state so in the original request for hearing. At the order of presentation will be:

  • 1.

    PEC Chair will request that an overview of the issues be provided;

  • 2.

    Both parties will be asked to verify that the facts were stated correctly and that all issues were raised;

  • 3.

    the Provider will be asked to present the Provider’s information and position on each issue;

  • 4.

    PEC panel members will be given the opportunity to ask questions and the Provider to respond to each question;

  • 5.

    Zenith will be asked to present its information and position on each issue;

  • 6.

    PEC panel members will be given the opportunity to ask questions and Zenith to respond to each question;

  • 7.

    Provider will be given the opportunity to respond to Zenith presentation;

Rev. 2-09

Page 6 of 7

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