WAC 388-538-0111 Primary care case management (PCCM) grievances and appeals.

1. A managed care enrollee may be enrolled in a managed care organization (MCO) or with a primary care case management (PCCM) provider. This section contains information about the grievance system for PCCM enrollees, which includes grievances and appeals. See WAC 388-538-0110 for information about the grievance system for MCO enrollees, which includes grievances and appeals. See WAC 388-538-0112 for the fair hearing process for appeals by MCO enrollees.

2. A PCCM enrollee may voice a grievance or appeal an MAA action, either orally or in writing. PCCM enrollees use the medical assistance administration's (MAA's) grievance and appeal processes.

3. The grievance process for PCCM enrollees; 

   1. A PCCM enrollee may file a grievance with MAA. A provider may not file a grievance on behalf of a PCCM enrollee.

   2. MAA provides PCCM enrollees with information equivalent to that described in WAC 388-538-0110 (7)(c).

   3. When a PCCM enrollee files a grievance with MAA, the enrollee is entitled to:

      1. Any reasonable assistance in taking procedural steps for grievances (e.g., interpreter services and toll-free numbers);

      2. Acknowledgment of MAA's receipt of the grievance;

      3. A review of the grievance. The review must be conducted by an MAA representative who was not involved in the grievance issue; and

      4. Disposition of a grievance and notice to the affected parties within ninety days of MAA receiving the grievance.

4. The appeal process for PCCM enrollees:

   1. A PCCM enrollee may file an appeal of an MAA action with MAA. A provider may not file an appeal on behalf of a PCCM enrollee.

   2. MAA provides PCCM enrollees with information equivalent to that described in WAC 388-538-0110 (8)(c).

   3. The appeal process for PCCM enrollees follows that described in chapter 388-02 WAC. Where a conflict exists, the requirements in this chapter take precedence.