Date of Adoption: November 21, 2001.

Purpose: The rules for basic health appeals are revised in order to streamline the process and incorporate changes prompted by passage of 2SSB 6199, Patients' Bill of Rights.

Citation of Existing Rules Affected by this Order: Amending WAC 182-25-105 and 182-25-110.

Statutory Authority for Adoption: RCW 70.47.050.

Adopted under notice filed as WSR 01-20-089 on October 2, 2001.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 2, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 2, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 2, Repealed 0.
Effective Date of Rule: January 1, 2002.

November 21, 2001

Melodie Bankers

Rules Coordinator

OTS-5203.1

AMENDATORY SECTION(Amending WSR 99-07-078, filed 3/18/99, effective 4/18/99)

WAC 182-25-105   How to appeal health care authority (HCA) decisions.   (1) ((Under this section, enrollees or applicants may file appeals of)) Health care authority decisions regarding the following may be appealed under this section:

(a) Eligibility((,));

(b) Premiums((,));

(c) Premium adjustments or penalties((,));

(d) Enrollment((,));

(e) Suspension((,));

(f) Disenrollment((,)); or ((a member's))

(g) Selection of managed health care system (MHCS).

(2) To appeal a health care authority (((HCA))) decision, enrollees or applicants must send a letter of appeal to the HCA ((appeals committee)). The letter of appeal must be signed by the appealing party and received by the HCA within thirty calendar days of the date of the decision. The letter of appeal must include:

(a) The name, mailing address, and BHP account number of the subscriber or applicant;

(b) The name and address of the enrollee or applicant affected by the decision, if that person is not the subscriber on the account;

(c) A copy of the HCA notice of the decision that is being appealed or, if the notice is not available, a statement of the decision being appealed; ((and))

(d) A statement explaining why the appealing party believes the decision was incorrect, outlining the facts surrounding the decision and including supporting documentation; and

(e) If the appealing party is not an enrollee or the subscriber on the account, a signed agreement from the enrollee, authorizing the appealing party to act on his/her behalf.

(3) ((Upon receiving the letter of)) When an appeal is received, the HCA will send ((notification)) a notice to the appealing party, confirming that the appeal has been received and indicating when a decision can be expected. If the appealing party is not an enrollee on the affected BHP account, the notice will also be sent to the subscriber.

(4) Initial HCA decisions: The HCA will conduct appeals according to RCW 34.05.485. The HCA appeals committee or a single presiding officer designated by the HCA will review and decide the appeal. The appealing party may request an opportunity to be present in person or by telephone to explain his or her view. If the appealing party does not request an opportunity to be present to explain, the HCA appeals committee or ((a hearings)) presiding officer ((designated by the HCA)) will review and decide the appeal based on the information and documentation submitted ((documents unless the HCA and the appealing party agree to hold a hearing in person or by telephone)).

(5) The HCA will give priority handling to appeals regarding a loss of coverage for an enrollee with an urgent medical need that could seriously jeopardize the enrollee's life, health, or ability to regain maximum function, provided:

(a) The appeal is received within ten business days of the effective date of the loss of coverage; and

(b) The enrollee has clearly stated in the letter of appeal or has otherwise notified the HCA that he or she has an urgent medical need.

(6) For all other appeals, the HCA will send the appealing party written ((notification)) notice of the ((appeals committee's or hearings officer's)) initial HCA decision within sixty days of receiving the letter of appeal. If the appealing party is not an enrollee on the affected BHP account, the notice will also be sent to the subscriber. The ((notification)) notice will include the reasons for ((their)) the initial decision((,)) and instructions on further appeal rights.

(((6))) (7) Review of initial HCA decision: The initial HCA decision ((of the appeals committee or hearings officer)) becomes the final agency decision unless the HCA receives a valid request for a review ((hearing)) from the appealing party.

(a) To be a valid request for review, the appealing party's request may be either verbal or in writing, but must:

(i) Be received within thirty days of the date of the initial HCA decision. ((The appealing party may request review of the initial decision either verbally or in writing. The person requesting review must reference))

(ii) Include a summary of the initial HCA decision being appealed and state why the appealing party believes the decision was incorrect; and

(iii) Provide any additional ((written)) information or documentation that the appealing party would like considered in the review.

(((a) If the appealing party))

(b) Requests ((a)) for review of ((the appeals committee's or hearings officer's)) an initial HCA decision regarding a disenrollment((,)) for nonpayment will be reviewed by the office of administrative hearings ((will review the decision)) through a hearing conducted under chapter 34.12 RCW and RCW 34.05.488 through 34.05.494.

(((b) If the appealing party))

(c) All other requests ((a)) for review of ((any)) an initial HCA decision ((of the appeals committee or hearings officer other than a disenrollment decision, a hearings)) will be reviewed by a presiding officer designated by the HCA ((will review the decision through a hearing conducted under)) according to the requirements of RCW 34.05.488 through 34.05.494, with the following exception: These review decisions will be based on the record and documentation submitted, unless the presiding officer decides that an in-person or telephone hearing is needed. If an in-person or telephone hearing is needed, the presiding officer will decide whether to conduct the hearing as an informal hearing or formal adjudicative proceeding.

(d) The presiding officer will issue a written notice of the review decision, giving reasons for the decision, within twenty-one days of receiving the request for review, unless the presiding officer finds that additional time is needed for the decision.

(((7) In a review under subsection (6)(a) or (b) of this section:

(a) The hearings officer will review and decide the appeal based on submitted documents unless the HCA and the appealing party agree to hold a hearing in person or by telephone.

(b) The review officer will make any inquiries necessary to determine whether the proceeding must become a formal adjudicative proceeding under the provisions of chapter 34.05 RCW.))

(8) ((If an enrollee submits a timely)) Enrollees who appeal ((of)) a disenrollment decision that was based on eligibility issues and not related to premium payments((, the enrollee will)) may remain enrolled during the appeal process, provided ((the enrollee)):

(a) The appeal was submitted according to the requirements of this section; and

(b) The enrollee:

(i) Remains otherwise ((remains)) eligible;

(((b))) (ii) Continues to make all premium payments when due; and

(((c))) (iii) Has not demonstrated a danger or threat to the safety or property of the MHCS or health care authority or their staff, providers, patients or visitors.

(9) ((An)) Enrollees who ((has appealed)) appeal a disenrollment decision related to nonpayment of premium or any issue other than eligibility will remain disenrolled during the appeal process.

(10) If the appealing party disagrees with a review decision under subsection (6) of this section, the appealing party may request judicial review of the decision, as provided for in RCW 34.05.542. Request for judicial review must be filed with the court within thirty days of service of the final agency decision.

[Statutory Authority: RCW 70.47.050. 99-07-078, 182-25-105, filed 3/18/99, effective 4/18/99; 98-07-002, 182-25-105, filed 3/5/98, effective 4/5/98; 96-15-024, 182-25-105, filed 7/9/96, effective 8/9/96.]

(2) Each MHCS must maintain a ((grievance)) complaint/appeals process for enrollees and must provide enrollees with instructions for filing a ((grievance)) complaint and/or appeal. This ((grievance)) complaint/appeals process must comply with ((HCA contract requirements for timeliness in responding to complaints, including procedures for an expedited review if the enrollee is urgently in need of medical care. In addition, the MHCS grievance/appeal process must include review of MHCS decisions by:

(a) MHCS personnel who have the authority to require corrective action; and

(b) Appropriate medical personnel, if the appeal includes complaints regarding quality of care or access to urgently needed services)) the requirements of chapter 48.43 RCW and chapter 284-43 WAC.

(3) ((An enrollee who has appealed a MHCS decision may ask)) On the request of the enrollee, the HCA ((to initiate informal dispute resolution in either of the following circumstances:

(a) The appeal has not been resolved within the timelines established by the MHCS grievance/appeal process or agreed to by the MHCS and the appealing party; or

(b) The enrollee has not received a response from the MHCS within thirty days of initiating the appeal. The response from the MHCS may be a decision or, if a delay of the appeal decision is necessary, it may be notification of a delay. If the decision has been delayed, the notice must include the reason for the delay and the date the enrollee can expect a decision from the MHCS. The HCA has the authority to determine if the delay is reasonable.

(i) If the HCA determines the delay to be unreasonable, the HCA will initiate informal dispute resolution.

(ii) If the HCA determines the delay to be reasonable, the HCA will not initiate informal dispute resolution unless the MHCS fails to issue a decision by the date indicated in the delay notice.

(4) Enrollees requesting informal dispute resolution must submit a written request to the HCA, which includes:

(a) The name, mailing address, and BHP account number of the subscriber;

(b) The name and address of the enrollee affected by the decision, if that person is not the subscriber on the account;

(c) A statement of the dispute and efforts to resolve it; and

(d) A statement, with facts and documentation, in support of the appealing party's opinion.

(5) When the HCA receives the request for informal dispute resolution, the HCA will notify the MHCS and will attempt to resolve the dispute. The HCA will notify the enrollee of the outcome of the informal dispute resolution or of the reason for a delay, within thirty days of receiving the request. If the issue has not been resolved to the satisfaction of the enrollee, the appealing party may ask the HCA appeals committee to review the MHCS decision. The request may be written or oral and must be received within thirty days of the date the HCA notifies the appealing party of the outcome of the informal dispute resolution. The appealing party may submit additional documentation with the request.

(6) Enrollees may appeal a final MHCS decision by sending a letter of appeal to the HCA appeals committee, asking for review of the final MHCS decision. The letter of appeal must be signed by the appealing party and received by the HCA within thirty days of the date of the final MHCS decision, and must include the information listed in subsection (4) of this section.

(7) The HCA will follow the procedures in WAC 182-25-105 (3) through (7) when conducting reviews of MHCS decisions. The MHCS must be given the opportunity to submit written comments or participate in any proceeding before the appeals committee or in any subsequent administrative review)) may assist an enrollee by:

(a) Attempting to informally resolve complaints against the enrollee's MHCS;

(b) Investigating and resolving MHCS contractual issues; and

(c) Providing information and assistance to facilitate review of the decision by an independent review organization.

[Statutory Authority: RCW 70.47.050. 99-07-078, 182-25-110, filed 3/18/99, effective 4/18/99; 96-15-024, 182-25-110, filed 7/9/96, effective 8/9/96.]

Washington State Code Reviser's Office