WAC 182-538-0111 Primary care case management (PCCM) grievances and appeals.

1. This section contains information about the grievance system for primary care case management (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 388-538-0110  about the grievance system for for managed care organization (MCO) enrollees.

2. A PCCM enrollee may voice a grievance or appeal, either orally or in writing. PCCM enrollees use the department's grievance and appeal processes.

3. The grievance process for PCCM enrollees; 

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

   2. The department 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 the department, 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 the department's receipt of the grievance;

      3. A review of the grievance. The review must be conducted by a department 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 the department receiving the grievance.

4. The appeal process for PCCM enrollees:

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

   2. The department 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.