Administrative Hearings - Special Procedures

Revised December 28, 2011

CLARIFYING INFORMATION

Effective July 1, 2011, the Health Care Authority became the single state Medicaid agency responsible for all medical assistance programs (Title XIX of the federal Social Security Act), State Children’s Health Insurance (S-CHIP) program (Title XXI of the federal Social Security Act), and state funded Medical Care Services (MCS) programs. These programs are collectively known as the “Medical Services Programs.”  Through an interagency agreement between HCA and DSHS, DSHS continues to provide all the services it previously provided in managing these cases. However, the legal jurisdiction for the Medical Services Programs moved from RCW 74.08.080 to Section 53, Laws of 2011, Chapter 15.  The AHC who previously represented the Department in these cases now represents the Health Care Authority as the HCA Hearing Representative. The Office of Administrative Hearings schedules these hearings as an HCA Hearing and will send a notice of the hearing to the DSHS AHC. If you have questions, please call the HCA Appeals Administrator at (360) 725-1254.

There are some hearings that are scheduled on the CSO docket but involve decisions made by other agencies and/or administrations. These hearings include:

-Non Grant Medical Assistance decisions made by Division of Disability Determination Services (DDDS).

-Medical Assistance decisions made by the Health Care Authority regarding:

a.       Medical equipment and services, or

b.      Managed care eligibility or services, or

c.       Restricted use of medical care, or

d.      Coordination of Benefits (TPL)issues.

In some cases, someone may represent the department from the agency or office that made the decision.

In some cases, the AHC will act as the agency representative, and the other office or agency will provide a witness to testify regarding the decision.

AHC RESPONSIBILITIES

There are several offices within the Health Care Authority (HCA) that make decisions which are subject to administrative hearings. It is important to contact the appropriate office as soon as a notice of hearing is received to coordinate representation.

1. Medical assistance hearings:
   1. For hearings involving medical services, equipment, transportation, managed care enrollment, and Patient Review and Coordination (PRC) program contact the HCA’s Office of Hearings and Appeals at: MS 45504, 360-725-1254 or 1-800-351-6827.

The HCA staff may act as the agency’s representative for these cases, coordinate testimony of medical consultants, help you obtain additional medical information, and arrange medical examinations, if necessary.

The HCA Appeals Administrator will coordinate review and implementation of hearing decisions as required by HCA.

The DSHS AHC acts as liaison between HCA’s staff and the Appellant and their representative if required. For example, if the Appellant requests an in-person hearing and it is scheduled at the local CSO, the DSHS AHC may assist the ALJ and the Appellant during the hearing because HCA staff participates in the hearing telephonically from Olympia, WA.

2. Non-grant medical assistance (NGMA) hearings: The AHC acts as the agency representative, and a DDDS employee provides testimony to support the decision.  Clients have up to 90 days to request a hearing on a NGMA decision.  As soon as the hearing request is received:
   1. Initiate reconsideration of the original decision by completing in hard copy a DSHS 14-144, Transmittal Summary, and check the box for Fair Hearing Review. The reconsideration is a required step in the DDDS process prior to hearing. Request continuances as appropriate to allow sufficient time for the reconsideration.
   2. Forward the DSHS 14-144 and the DDDS original decision packet in hard copy to the appropriate DDDS office. Attach any new medical documentation and release of information authorizations, if appropriate.  (Do not use the automated BarCode referral process for administrative hearing reviews.) 
   3. Notify DDDS of the scheduled date and time of the hearing.
   4. Coordinate requested continuances from either the appellant or DDDS with the local OAH office. Continuances are often necessary in these cases to obtain additional medical information. It is important that the AHC keep all parties informed of the status of the case prior to the hearing.
   5. Notify the appellant if the original DDDS decision is reversed in the DDDS review process.
   6. If the original denial is affirmed in the DDDS review process, consult with the DDDS hearing supervisor who will assign someone to testify in support of the denial.

Pauline Douglas
Hearings Manager
(360) 664-7416

MS 45550