WAC 388-538-112
The department of social and health
services' (DSHS) hearing process for enrollee appeals of
managed care organization (MCO) actions. (1) The hearing
process described in chapter 388-02 WAC applies to the hearing
process described in this chapter. Where a conflict exists,
the requirements in this chapter take precedence.
(2) A managed care organization (MCO) enrollee
must exhaust all levels of resolution and appeal within the
MCO's grievance system prior to requesting a hearing with the
department. See WAC 388-538-110 for the MCO grievance system.
(3) If an MCO enrollee does not agree with the MCO's
resolution of the enrollee's appeal, the enrollee may file a
request for a department hearing within the following time
frames:
(a) For hearing requests regarding a standard service,
within ninety calendar days of the date of the MCO's notice of
the resolution of the appeal.
(b) For hearing requests regarding termination,
suspension, or reduction of a previously authorized service,
and the enrollee is requesting continuation of services,
within ten calendar days of the date on the MCO's notice of
the resolution of the appeal.
(4) The entire appeal and hearing process, including the
MCO appeal process, must be completed within ninety calendar
days of the date the MCO enrollee filed the appeal with the
MCO, not including the number of days the enrollee took to
subsequently file for a department hearing.
(5) Expedited hearing process:
(a) The office of administrative hearings (OAH) must
establish and maintain an expedited hearing process when the
enrollee or the enrollee's representative requests an
expedited hearing and OAH indicates that the time taken for a
standard resolution of the claim could seriously jeopardize
the enrollee's life or health and ability to attain, maintain,
or regain maximum function.
(b) When approving an expedited hearing, OAH must issue a
hearing decision as expeditiously as the enrollee's health
condition requires, but not later than three business days
after receiving the case file and information from the MCO
regarding the action and MCO appeal.
(c) When denying an expedited hearing, OAH gives prompt
oral notice to the enrollee followed by written notice within
two calendar days of request and transfer the hearing to the
time frame for a standard service.
(6) Parties to the hearing include the department, the
MCO, the enrollee, and the enrollee's representative or the
representative of a deceased enrollee's estate.
(7) If an enrollee disagrees with the hearing decision,
then the enrollee may request an independent review (IR) in
accordance with RCW 48.43.535.
(8) If there is disagreement with the IR decision, any
party may request a review by the department's board of
appeals (BOA) within twenty-one days of the IR decision. The
department's BOA issues the final administrative decision.
[Statutory Authority: RCW 74.08.090 and 74.09.522. 08-15-110, § 388-538-112, filed 7/18/08, effective 8/18/08;
06-03-081, § 388-538-112, filed 1/12/06, effective 2/12/06. Statutory Authority: RCW 74.08.090, 74.09.522, 2003 E1 c 25 §
201(4), 2004 c 276 § 201(4), 42 USC 1396N (section 1915 (b)
and (c) of the Social Security Act of 1924). 05-01-066, §
388-538-112, filed 12/8/04, effective 1/8/05. Statutory
Authority: RCW 74.08.090, 74.09.522, and 74.09.450. 04-13-002, § 388-538-112, filed 6/2/04, effective 7/3/04. Statutory Authority: RCW 74.08.090, 74.09.522. 03-18-110, §
388-538-112, filed 9/2/03, effective 10/3/03.]