WSR 08-01-085

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed December 17, 2007, 11:25 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 07-21-030.

Title of Rule and Other Identifying Information: The department is amending WAC 388-501-0135 Patient review and restriction program (PRR).

Hearing Location(s): Office Building 2 - Auditorium (DSHS Headquarters), 1115 Washington, Olympia, WA 98504 (public parking at 11th and Jefferson. A map is available at http://www1.dshs.wa.gov/msa/rpau/RPAU-OB-2directions.html or by calling (360) 664-6094), on January 22, 2008, at 10:00 a.m.

Date of Intended Adoption: Not earlier than January 23, 2008.

Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504-5850, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail DSHSRPAURulesCoordinator@dshs.wa.gov, fax (360) 664-6185, by 5 p.m. on January 22, 2008.

Assistance for Persons with Disabilities: Contact Jennisha Johnson, DSHS Rules Consultant, by January 15, 2008, TTY (360) 664-6178 or (360) 664-6094 or by e-mail at johnsjl4@dshs.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The rule is being amended to: (1) Change program name to patient review and coordination (PRC) program, (2) expand program definitions, (3) clarify restrictions, (4) add a requirement that the PRC clients remain enrolled in the managed care plans for one year, and (5) clarify client dispute resolution process.

Reasons Supporting Proposal: This revision provides added clarification, changes the program name to reflect program coordination activities, and adds a new program placement requirement to provide continuity of care coordination.

Statutory Authority for Adoption: RCW 74.08.090, 42 C.F.R. 431.51, 431.54(e) and 456.1, 42 U.S.C. 1396N.

Statute Being Implemented: RCW 74.08.090, 42 C.F.R. 431.51, 431.54(e) and 456.1, 42 U.S.C. 1396N.

Rule is necessary because of federal law, 42 C.F.R. 431.51, 431.54(e) and 456.1, 42 U.S.C. 1396N.

Name of Proponent: Department of social and health services, governmental.

Name of Agency Personnel Responsible for Drafting: Jonell O. Blatt, 626 8th Avenue, Olympia, WA 98504, (360) 725-1571; Implementation and Enforcement: Trang T. Kuss, 626 8th Avenue, Olympia, WA 98504, (360) 725-1391.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The revision to this rule does not affect small businesses.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Trang Kuss, P.O. Box 45532, Olympia, WA 98504-5532, phone (360) 725-1391, fax (360) 725-1969, e-mail kusstt@dshs.wa.gov.

December 13, 2007

Stephanie E. Schiller

Rules Coordinator

3933.5
AMENDATORY SECTION(Amending WSR 06-14-062, filed 6/30/06, effective 7/31/06)

WAC 388-501-0135   Patient review and ((restriction (PRR))) coordination (PRC).   (1) Patient review and ((restriction (PRR))) ((is a health and safety program for medical assistance fee-for-service clients and managed care organization (MCO) enrollees needing help with using medical services appropriately. PRR is authorized under federal Medicaid law by 42 USC 1396n (a)(2) and 42 CFR 431.54)) coordination (PRC) program, formerly known as the patient review and restriction (PRR) program, coordinates care and ensures that clients selected for enrollment in PRC use services appropriately and in accordance with department rules and policies.

(a) PRC applies to medical assistance fee-for-service and managed care clients. PRC does not apply to clients eligible for the family planning only program.

(b) PRC is authorized under federal Medicaid law by 42 USC 1396n (a)(2) and 42 CFR 431.54.

(2) Definitions. The following definitions apply to this section only:

"Appropriate use" ((means)) - Use of ((health care)) healthcare services that are adapted to or appropriate for a client's ((or enrollee's medical)) healthcare needs.

"Assigned provider" ((means)) - A department-enrolled healthcare provider or one participating with a department contracted managed care organization (MCO) ((contracted medical provider)) who agrees to be assigned as a primary provider and coordinator of services for a ((medical assistance)) fee-for-service or managed care client ((or MCO enrollee)) in the ((PRR)) PRC program. Assigned providers can include a primary care provider (PCP), a pharmacy, a ((narcotic)) controlled substances prescriber, and((,)) a hospital for ((nonemergency medical)) nonemergent hospital services((, a hospital)).

"At-risk" ((means a medical history that may include)) - A term used to describe one or more of the following:

(a) A client with a medical history of:

((Indicators)) Indications of forging or altering prescriptions;

Seeking and/or obtaining ((medical)) healthcare services at a frequency or amount that is not medically necessary;

((Indicators of potentially)) Potential life-threatening events or life-threatening conditions that required or may require medical intervention((;

A client's or enrollee's medical assistance identification card reportedly used by an unauthorized person(s) or for an unauthorized purpose(s); or

)).

(b) ((Other)) Behaviors or practices that could jeopardize a client's ((or enrollee's)) medical treatment or health including, but not limited to:

Referrals from social services personnel about inappropriate behaviors or practices that places the client at risk;

Noncompliance with treatment;

Paying cash for controlled substances;

Positive urine drug screen for illicit street drugs or nonprescribed controlled substances; or

Unauthorized use of a client's medical assistance identification card or for an unauthorized purpose.

"Care management" - Services provided to clients with multiple health, behavioral, and social needs in order to improve care coordination, client education, and client self-management skills.

"Client" - A person enrolled in a department healthcare program and receiving service from fee-for-service provider(s) or a managed care organization (MCO), contracted with the department.

"Conflicting" ((means)) - Drugs and/or ((health care)) healthcare services that are incompatible and/or unsuitable for use together because of undesirable chemical or physiological effects.

"Contraindicated" ((means)) - To indicate or show ((that)) a medical treatment or procedure is inadvisable or not recommended or warranted.

"Controlled substances prescriber" - Any of the following healthcare professionals who, within their scope of professional practice, are licensed to prescribe and administer controlled substances (see chapter 69.50 RCW, uniform controlled substance act) for a legitimate medical purpose:

A physician under chapter 18.71 RCW;

A physician assistant under chapter 18.71A RCW;

An osteopathic physician under chapter 18.57 RCW;

An osteopathic physician assistant under chapter 18.57A RCW; and

An advanced registered nurse practitioner under chapter 18.79 RCW.

"Duplicative" - Applies to the use of the same or similar drugs and ((health care)) healthcare services without due justification. Example: A client (((or MCO enrollee))) receives ((health care)) healthcare services from two or more providers for the same or similar condition(s) in an overlapping time frame, or the client receives two or more similarly acting drugs in an overlapping time frame, which could result in a harmful drug interaction or an adverse reaction.

"Just cause" - A legitimate reason to justify the action taken, including but not limited to, protecting the health and safety of the client.

"Managed care organization" or "MCO" ((means)) - An organization having a certificate of authority or certificate of registration from the office of insurance commissioner, that contracts with the department under a comprehensive risk contract to provide prepaid ((health care)) healthcare services to eligible medical assistance clients under the department's managed care programs.

"((MCO enrollee)) Managed care client" ((means)) - A medical assistance client enrolled in, and receiving ((medical)) healthcare services from, a department-contracted managed care organization (MCO).

(("Narcotic prescriber" means any of the following health care professionals who, within their scope of professional practice, are licensed to prescribe and administer controlled substances (see chapter 69.50 RCW, Uniform Controlled Substance Act) for a legitimate medical purpose:

A physician under chapter 18.71 RCW;

A physician assistant under chapter 18.71A RCW;

An osteopathic physician under chapter 18.57 RCW;

An osteopathic physician assistant under chapter 18.57A RCW; and

An advanced registered nurse practitioner under chapter 18.79 RCW.))

"Primary care provider" or "PCP" ((means)) - A person licensed or certified under title 18 RCW including, but not limited to, a physician, an advanced registered nurse practitioner (ARNP), or a physician assistant who supervises, coordinates, and provides ((health care)) healthcare services to a client ((or an MCO enrollee)), initiates referrals for specialty and ancillary care, and maintains the client's ((or enrollee's)) continuity of care.

(3) ((Restrictions under the PRR program:

(a) Do not apply to a client eligible for a family planning only program; and

(b) Do apply to a fee-for-service client or an MCO enrollee currently assigned to the PRR program)) Clients selected for PRC review. The department or MCO selects a client for PRC review when either or both of the following occur:

(a) A utilization review report indicates the client has not utilized healthcare services appropriately; or

(b) Medical providers, social service agencies, or other concerned parties have provided direct referrals to the department or MCO.

(4) When a fee-for-service client is selected for PRC review the prior authorization process ((described in WAC 388-530-1250)) as defined in chapter 388-530 WAC may be required ((for a fee-for-service client)):

(a) Prior to or during a ((PRR)) PRC review; or

(b) When currently ((placed)) in the ((PRR)) PRC program.

(5) ((Clients selected for PRR review. The department or MCO selects a fee-for-service client or MCO enrollee for PRR review when either or both of the following occur:

(a) A utilization review report indicates the client or enrollee has utilized health care services as described in subsection (6) of this section; or

(b) Medical providers, social service agencies, or other concerned parties have provided direct referrals to the department or MCO.

(6))) ((PRR)) Review for placement in the ((PRR)) PRC program. When the department or MCO selects a client ((or enrollee)) for ((PRR)) PRC review, the department or MCO staff, with clinical oversight, reviews a client's ((or enrollee's)) medical and/or billing history to determine if the client ((or enrollee)) has utilized ((medical)) healthcare services at a frequency or amount that is not medically necessary (42 CFR 431.54(e)). ((The utilization guidelines in subsection (7) of this section establish that a client or enrollee has utilized medical services at a frequency or amount that is not medically necessary when:

(a) There is a history of medical services that are duplicative, excessive, or contraindicated;

(b) There is a history of conflicting health care services, drugs, or supplies that are not within acceptable medical practice; or

(c) The medical history shows indicators of "at-risk" utilization patterns.

(7))) (6) Utilization guidelines for ((PRR)) PRC placement. Department ((and)) or MCO staff use the following utilization guidelines to determine ((PRR)) PRC placement ((and)). A client may be placed ((a client or enrollee)) in the ((PRR)) PRC program when medical and/or billing histories document any of the following:

(a) Any two or more of the following conditions occurred in a period of ninety consecutive calendar days in the previous twelve months. The client ((or enrollee)):

(i) Received services from four or more different providers, including physicians, advanced registered nurse practitioners (ARNPs), and physician assistants (PAs);

(ii) Had prescriptions filled by four or more different pharmacies;

(iii) Received ten or more prescriptions;

(iv) Had prescriptions written by four or more different prescribers;

(v) Received similar services from two or more providers in the same day; or

(vi) Had ten or more office visits.

(b) Any one of the following occurred within a period of ninety consecutive calendar days in the previous twelve months. The client ((or enrollee has)):

(i) Made two or more emergency department visits;

(ii) Has a medical history that indicates "at-risk" utilization patterns;

(iii) Made repeated and documented efforts to seek ((health care)) healthcare services that are not medically necessary; or

(iv) Has been counseled at least once by a health care provider, or a department or MCO staff member, with clinical oversight, about the appropriate use of ((health care)) healthcare services.

(c) The client ((or enrollee)) received prescriptions for controlled substances from two or more different prescribers in any one month in the previous twelve months.

(d) The client's medical and/or billing history demonstrates a pattern of the following at any time within a one-year period:

(i) The client has a history of using healthcare services in a manner that is duplicative, excessive, or contraindicated; or

(ii) The client has a history of receiving conflicting healthcare services, drugs, or supplies that are not within acceptable medical practice.

(((8))) (7) ((PRR)) PRC review ((outcomes)) results. As a result of the ((PRR)) PRC review, the department or MCO staff may take any of the following steps:

(a) Determine that no action is needed and close the client's ((or enrollee's)) file;

(b) Send the client ((or enrollee)) and, if applicable, the client's ((or enrollee's)) authorized representative, a letter of concern with information on specific findings and notice of potential placement in the ((PRR)) PRC program; or

(c) Determine that the utilization guidelines for ((PRR)) PRC placement establish that the client ((or enrollee)) has utilized ((medical)) healthcare services at an amount or frequency that is not medically necessary ((and)), in which case the department or MCO will take one or more of the following actions((. The department or MCO staff)):

(i) Refer((s)) the client ((or enrollee)) for education on appropriate use of ((health care)) healthcare services;

(ii) Refer((s)) the client ((or enrollee)) to other support services or agencies; or

(iii) Place((s)) the client ((or enrollee)) into the ((PRR)) PRC program for an initial ((restriction)) placement period of twenty-four months.

(((9))) (8) ((PRR)) Initial placement in the PRC program ((placement)). When a ((fee-for-service)) client ((or MCO enrollee)) is initially placed in the ((PRR)) PRC program((, the department or the MCO sends the client or enrollee and, if applicable, the client's or enrollee's authorized representative, a written notice of the PRR placement that:

(a) Informs the client or the enrollee of the reason for the PRR program placement.

(b) Restricts)):

(a) The department or MCO places the client ((or enrollee)) for twenty-four months ((to)) with one or more of the following types of ((providers when obtaining health care services)) healthcare providers:

(i) Primary care ((physician)) provider (PCP) (as defined in subsection (2) of this section);

(ii) Pharmacy;

(iii) ((Narcotic)) Controlled substances prescriber;

(iv) Hospital (for ((nonemergency medical)) nonemergent hospital services); or

(v) Another qualified ((provider-type)) provider type, as determined by department or MCO program staff on a case-by-case basis.

(((c) Directs the client or enrollee to respond to the department or the MCO within ten days of the date of the written notice:

(i) To select providers, subject to department or MCO approval;

(ii) To submit additional medical information, justifying the client's or enrollee's use of medical services; or

(iii) To request assistance, if needed, from the department or MCO program staff.

(d) Informs the client or enrollee of hearing rights (see subsection (14) of this section).

(e) Informs the client or enrollee that if a response is not received within ten days of the date of the notice, the client or enrollee will be assigned providers.

(f) Informs the client or enrollee of the rules that support the decision)) (b) The managed care client will remain in the same MCO for no less than twelve months unless:

(i) The client moves to a residence outside the MCO's service area and the MCO is not available in the new location; or

(ii) The client's assigned provider no longer participates with the MCO and is available in another MCO, and the client wishes to remain with the current provider.

(c) A managed care client placed in the PRC program must remain in the PRC program for the initial twenty-four month period regardless of whether the client changes MCOs or becomes a fee-for-service client.

(d) A care management program may be offered to a client.

(9) Notifying the client about placement in the PRC program. When the client is initially placed in the PRC program, the department or the MCO sends the client and, if applicable, the client's authorized representative, a written notice containing at least the following components:

(a) Informs the client of the reason for the PRC program placement;

(b) Directs the client to respond to the department or MCO within ten business days of the date of the written notice about taking the following actions:

(i) Select providers, subject to department or MCO approval;

(ii) Submit additional healthcare information, justifying the client's use of healthcare services; or

(iii) Request assistance, if needed, from the department or MCO program staff.

(c) Informs the client of hearing or appeal rights (see subsection (14) of this section).

(d) Informs the client that if a response is not received within ten days of the date of the notice, the client will be assigned a provider(s) by the department or MCO.

(10) Selection and role of assigned provider. A ((fee-for-service)) client ((and an MCO enrollee)) may be afforded a limited choice of providers ((for the types of services that are to be restricted (see subsection (9)(a) of this section for a list of provider-types that the department may assign))).

(a) The following providers are not available:

(i) A provider who is being reviewed by the department or licensing authority regarding quality of care;

(ii) A provider who has been suspended or disqualified from participating as a department-enrolled or MCO-contracted provider; or

(iii) A provider whose business license is suspended or revoked by the licensing authority.

(b) For a ((fee-for-service)) client placed in the ((PRR)) PRC program, the assigned:

(i) Provider(s) must be located in the client's local geographic area, in the client's selected MCO, and/or be reasonably accessible to the client.

(ii) ((Department-enrolled)) Primary care provider (PCP) supervises and coordinates ((health care)) healthcare services for the client, including ((providing)) continuity of care and referrals to specialists when necessary. The PCP must be one of the following:

(A) A physician who meets the criteria ((under WAC 388-502-0020 and 388-502-0030)) as defined in chapter 388-502 WAC;

(B) An advanced registered nurse practitioner (ARNP) who meets the criteria ((under WAC 388-502-0020 and 388-502-0030)) as defined in chapter 388-502 WAC; or

(C) A licensed physician assistant (PA), practicing with a ((sponsored)) supervising physician.

(iii) ((Narcotic)) Controlled substances prescriber prescribes all controlled substances for the client.

(iv) Pharmacy fills all prescriptions for the client.

(v) Hospital provides all ((nonemergency and outpatient hospital care for the client)) nonemergent hospital services.

(((b) For an MCO enrollee placed in the PRR program, the assigned PCP, narcotic prescriber, pharmacy, and hospital must be:

(i) Available within the enrollee's selected MCO; and

(ii) Located in the enrollee's local geographic area and/or reasonably accessible to the enrollee.))

(c) A client ((or enrollee)) placed in the ((PRR)) PRC program cannot change assigned providers for twelve months after the assignments are made, unless:

(i) The client ((or enrollee)) moves to a residence outside the provider's geographic area;

(ii) The provider moves out of the client's ((or enrollee's)) local geographic area and is no longer reasonably accessible to the client ((or enrollee));

(iii) The provider refuses to continue to serve the client ((or enrollee));

(iv) The client ((or enrollee)) did not select the provider. The client ((or enrollee)) may request to change an assigned provider once within thirty calendar days of the initial assignment;

(v) The ((enrollee's)) client's assigned provider no longer participates with the MCO. In this case, the ((enrollee)) client may select a new provider from the list of available providers in the MCO or ((transfer enrollment of all family members to the new department-contracted MCO that the established provider has joined;

(vi) The provider has been suspended or disqualified from participating as a department-enrolled or MCO-contracted provider; or

(vii) The provider's business license has been suspended or revoked by the licensing authority;)) follow the assigned provider to the new MCO.

(d) When an assigned prescribing provider no longer contracts with the department:

(i) All prescriptions from the provider are invalid thirty calendar days following the date the contract ends; and

(ii) All prescriptions from the provider are subject to applicable ((pharmacy)) prescription drugs (outpatient) rules in chapter 388-530 WAC or appropriate MCO rules((; and)).

(iii) The client ((or enrollee)) must choose or be assigned another provider according to the requirements in this section.

(11) ((PRR restriction)) PRC placement periods. The length of time for a ((fee-for-service)) client's ((or MCO enrollee's)) PRC placement includes:

(a) The initial ((restriction)) period of ((PRR)) PRC placement, which is((:

(i) A minimum of twenty-four consecutive months; or

(ii) If the client or enrollee is not eligible for a medical assistance program for any month(s) during the span of the twenty-four consecutive months of PRR placement, the restriction period is for the duration of the client's or enrollee's medical assistance program eligibility plus any subsequent period of eligibility up to but not exceeding twenty-four months;)) a minimum of twenty-four consecutive months.

(b) The second ((restriction)) period of ((PRR)) PRC placement, which is((:

(i) An additional thirty-six consecutive months; or

(ii) If the client or enrollee is not eligible for a medical assistance program for any month(s) during the span of the thirty-six consecutive months, the restriction period is for the duration of the client's or enrollee's eligibility for a medical assistance program plus any subsequent period of eligibility up to but not exceeding thirty-six months; and)) an additional thirty-six consecutive months.

(c) The third ((restriction)) period and each subsequent period of ((PRR)) PRC placement, which is((:

(i) An additional seventy-two consecutive months; or

(ii) If the client or enrollee is not eligible for a medical assistance program for any month(s) during the span of the seventy-two consecutive months, the restriction period is for the duration of the client's or enrollee's eligibility for a medical assistance program plus any subsequent period of eligibility up to but not exceeding each seventy-two month placement)) an additional seventy-two months.

(12) Department review of a ((PRR restriction)) PRC placement period ((assignment)). The department or MCO reviews a ((fee-for-service)) client's ((or MCO enrollee's)) use of ((health care)) healthcare services prior to the end of each ((assigned PRR restriction)) PRC placement period described in subsection (11) of this section using the utilization guidelines in subsection (((7))) (6) of this section.

(a) The department or MCO assigns the next ((PRR restriction)) PRC placement period if the utilization guidelines for ((PRR)) PRC placement in subsection (((7))) (6) apply to the client ((or enrollee)).

(b) When the department or MCO assigns a subsequent ((PRR restriction)) PRC placement period, the department or MCO sends the client ((or enrollee)) and, if applicable, the client's ((or enrollee's)) authorized representative, a written notice ((that informs)) informing the client ((or enrollee)):

(i) ((Of)) The reason for the subsequent ((PRR)) PRC program placement;

(ii) ((Of)) The ((period of time)) length of the subsequent ((PRR)) PRC placement;

(iii) That the current providers assigned to the client ((or enrollee)) continue to be assigned to the client during the subsequent ((PRR restriction)) PRC placement period;

(iv) That all ((PRR)) PRC program rules continue to apply; and

(v) Of hearing or appeal rights (see subsection (14) of this section); ((and))

(vi) Of the rules that support the decision.

(c) The department may ((lift any assigned PRR restriction period)) remove a client from PRC placement if the client ((or enrollee)):

(i) Successfully completes a treatment program that is provided by a chemical dependency service provider certified by the department under chapter 388-805 WAC;

(ii) Submits documentation of completion of the approved treatment program to the department; and

(iii) Maintains appropriate use of ((health care)) healthcare services within the utilization guidelines described in subsection (((7))) (6) for six months after the date the treatment ends.

(d) ((A client or enrollee who is placed in the PRR program after being removed from any PRR restriction period will be placed at the next PRR restriction period described in subsections (11)(b) and (c) of this section)) The department or MCO determines the appropriate placement period for a client who has been placed back into the program.

(e) A client ((or enrollee)) will remain placed in the ((PRR)) PRC program regardless of change in eligibility program type or change in address.

(13) Client financial responsibility. ((This subsection takes precedence over WAC 388-502-0160.)) A ((fee-for-service)) client ((or MCO enrollee)) placed in the ((PRR)) PRC program may be billed by a provider and held financially responsible for ((health care)) healthcare services when the client ((or enrollee)) obtains ((nonemergency)) nonemergent services and the provider who renders the services is not assigned or referred under the ((PRR)) PRC program.

(14) Right to hearing or appeal.

(a) A fee-for-service client ((or MCO enrollee)) who believes the department ((or MCO)) has taken an invalid action ((erroneously)) pursuant to this section may request a hearing.

(b) A managed care client who believes the MCO has taken an invalid action pursuant to this section or chapter 388-538 WAC must exhaust the MCO's internal appeal process set forth in WAC 388-538-110 prior to requesting a hearing. Managed care clients can not change MCOs until the appeal or hearing is resolved and there is a final ruling.

(((a))) (c) A client ((or enrollee)) must request the hearing or appeal within ninety calendar days after the client ((or enrollee)) receives the written notice of ((restriction)) placement in the PRC program. ((Chapter 388-538 WAC does not apply to the department's or MCO's decision to place an enrollee in the PRR program.

(b))) (d) The department conducts a hearing according to chapter 388-02 WAC. Definitions for the terms "hearing," "initial order," and "final order" used in this subsection are found in WAC 388-02-0010.

(((c))) (e) A client ((or enrollee)) who requests a hearing or appeal within ten calendar days from the date of the written notice of an initial ((restriction)) PRC placement period ((of PRR placement)) under subsection (11)(a) of this section will not be placed in the ((PRR)) PRC program until the date an initial order is issued that supports the client's ((or enrollee's)) placement in the ((PRR)) PRC program or otherwise ordered by an administrative law judge (ALJ).

(((d))) (f) A client ((or enrollee)) who requests a hearing ((after)) or appeal more than ten calendar days from the date of the written notice under subsection (((11)(a))) (9) of this section will remain placed in the ((PRR)) PRC program unless a final administrative order is entered that orders ((their)) the client's removal from ((restriction)) the program.

(((e))) (g) A client ((or enrollee)) who requests a hearing or appeal within ninety days from the date of receiving the written notice under subsection (((11)(b) or (c) or)) (9) of this section and who has already been assigned providers will remain placed in the ((PRR)) PRC program unless a final administrative order is entered that orders the client's ((or enrollee's)) removal from ((restriction)) the program.

(((f))) (h) An administrative law judge (ALJ) may rule that the client ((or enrollee)) be placed in the ((PRR)) PRC program prior to the date the record is closed and prior to the date the initial order is issued based on a showing of just cause (((a showing of just cause means it has been demonstrated that there is a legitimate cause to justify the action taken) to protect the health and safety of the client or enrollee)).

(i) The client who requests a hearing challenging placement into the PRC program has the burden of proving the department's or MCO's action was invalid. For standard of proof, see WAC 388-02-0485.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.04.055, and 42 C.F.R. 431.54. 06-14-062, 388-501-0135, filed 6/30/06, effective 7/31/06. Statutory Authority: RCW 74.08.090, 74.04.055, and 42 C.F.R. Subpart B 431.51, 431.54 (e) and (3), and 456.1. 04-01-099, 388-501-0135, filed 12/16/03, effective 1/16/04. Statutory Authority: RCW 74.08.090. 01-02-076, 388-501-0135, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, 388-501-0135, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 74.09.522. 97-03-038, 388-501-0135, filed 1/9/97, effective 2/9/97. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), 388-501-0135, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-100.]

Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.

Washington State Code Reviser's Office