WSR 04-13-002

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed June 2, 2004, 3:19 p.m. , effective July 3, 2004 ]


Purpose: On September 2, 2003, the Medical Assistance Administration (MAA) filed a rule-making order amending chapter 388-538 WAC, Managed care, under WSR 03-18-110. Due to an administrative error, the rule omitted listing the department as a party to the MAA fair hearing, and did not clearly state the time limits to request a fair hearing. This amendment corrects these omissions.

Citation of Existing Rules Affected by this Order: Amending WAC 388-538-112.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.522.

Other Authority: RCW 74.09.450.

Adopted under notice filed as WSR 04-07-135 on March 22, 2004.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.

Date Adopted: May 28, 2004.

May 28, 2004

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3378.1
AMENDATORY SECTION(Amending WSR 03-18-110, filed 9/2/03, effective 10/3/03)

WAC 388-538-112   The medical assistance administration's (MAA's) fair hearing process for enrollee appeals of managed care organization (MCO) actions.   (1) The fair hearing process described in chapter 388-02 WAC applies to the fair 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 fair hearing) with MAA. See WAC 388-538-110 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 fair hearing within the following time frames:

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

(b) For appeals regarding termination, suspension, or reduction of a previously authorized service, or 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 fair hearing.

(5) Parties to the ((MAA)) fair hearing include the department, the MCO, the enrollee, and the enrollee's representative or the representative of a deceased enrollee's estate.

(6) If an enrollee disagrees with the ((department)) fair hearing decision, then the enrollee may request an independent review (IR) ((per)) in accordance with RCW 48.43.535.

(7) If there is disagreement with the IR decision, the ((state)) department of social and health services (DSHS) board of appeals (BOA) issues the final administrative decision.

[Statutory Authority: RCW 74.08.090, 74.09.522. 03-18-110, 388-538-112, filed 9/2/03, effective 10/3/03.]

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