Special Procedures on Non-Grant Medical Assistance and Health Care Authority hearings

Revised October 28, 2015

Clarifying Information:

Effective July 1, 2011, the Health Care Authority (HCA) 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 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 RCW 74.09.741.  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 divisions, agencies or administrations, including:

  • Non Grant Medical Assistance decisions made by Division of Disability Determination Services (DDDS).
  • Medical Assistance decisions made by the Health Care Authority regarding:
  1. Creation of a single state Medicaid agency:

    a) Medical equipment and services, or

         b) Managed care eligibility or services, or

         c) Restricted use of medical care, or

        d) Coordination of Benefits or Third Party Liability issues.

In some cases, someone may represent the department from the agency or office that made the decision (e.g. issue related to denial of a medical service or choice of a managed care plan).

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.

2. Transfer of administrative hearing rules for medical services programs from WAC 388-02 to WAC 182-526:

HCA now has its own hearing rules separate from DSHS hearing rules. Any hearing involving a medical services program will fall under the hearing rules listed in WAC 182-526. These rules are effective February 1, 2013. This means any hearing held on or after that date is subject to the rules listed in WAC 182-526.

Other important changes to the WACs include the following:

  • Definition updates for Limited English Proficiency clients and interpreters (WAC 182-526-0010, 182-526-0120 through 182-526-0150);
  • Clarification of the terms send (182-526-0040), serve (182-526-0045) and file (182-526-0070) in relation to documents for a hearing;
  • Pre-hearing conferences must still be granted if requested at least 7 business days before the scheduled hearing. The rule changed so the pre-hearing conference order must be served at least fourteen calendar days before the hearing, which may prevent OAH from having the pre-hearing conference on the same day as the hearing, unless parties voluntarily waive the timeliness requirements.

Administrative Hearing Coordinator Responsibilities:

There are several offices within the Health Care Authority (HCA) that make decisions that 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

A. 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.
  2. 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.
  3. The HCA Appeals Administrator will coordinate review and implementation of hearing decisions as required by HCA.
  4. 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.
  5. For insurance issues, contact HCA’s Revenue, Recovery and Premium Payment Section or HCA’s Coordination of Benefits (COB) Section, as appropriate:
    • COB Health Units: 1-800-562-3022 ext # 16134
    • COB Casualty Unit: 1-800-562-3022 ext # 15462
    • RRPS Premium Payment: 1-800-562-3022 ext # 15473
  6. For eligibility and policy issues, when clarification is required, contact the regional eligibility representative in the Office of Medicaid, Medicare, Eligibility & Policy (OMMEP), Eligibility Policy and Service Delivery (EPSD) - MS 45534.
  7. For hearings involving SCHIP (F07), Take Charge (P06), BCCTP (S30) or other cases assigned to CSO 76 contact Susie Bahr 360-725-1724  MS 45531
  8. For hearings involving a cash AND medical program, such as TANF or ABD, the AHC will need to cite the correct hearing rules when necessary, which may mean citing both the HCA hearing rules and the DSHS hearing rules. The administrative law judge will also need to use the correct rules when entering and serving an order. All ALJ decisions on HCA cases must be "initial orders", not "final orders."

B. 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. 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.
  2. Notify the appellant if the original DDDS decision is reversed in the DDDS review process.
  3. 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.
  4. Notify DDDS of the scheduled date and time of the hearing.
  5. 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.)
  6. Initiate reconsideration of the original decision by completing in hard copy a DSHS 14-144, Transmittal Summary, and check the box for the Administrative 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.

NOTE: A hearing request is not always needed for the Department to review a NGMA decision.  Clients may ask for a review within 30 days of the initial denial if medical evidence exists that was not used to make the original decision.  Please follow the above steps and note on the referral that it is a reconsideration of denial.

DDDS Hearings Contact:

Pauline Douglas
Hearings Manager
(360) 664-7416

MS 45550