WAC 388-538-0112

Effective February 6, 2006

WAC 388-538-0112 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. An MCO enrollee must exhaust all levels of resolution and appeal within the MCO's grievance system prior to filing an appeal (a request for a department hearing) with MAA. See WAC 388-538-0110 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:

    1. For appeals regarding a standard service, within ninety calendar days of the date of the MCO's notice of the resolution of the appeal.

    2. For appeals 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 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:

    1. When the enrollee or the enrollee's representative requests a hearing indicating 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, the office of administrative hearings (OAH) will approve or deny the request.

    2. When approving an expedited hearing, OAH will advise the enrollee, MCO and the department as expeditiously as the enrollee's health condition requires, but no later than three business days after receiving the case file from the MCO.

    3. When denying an expedited hearing, OAH will advise the enrollee orally within two days of request and confirm with a written decision with three business days after receiving the case file from the MCO:

  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, the department of social and health services (DSHS) board of appeals (BOA) issues the final administrative decision.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.