WSR 00-21-062

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed October 16, 2000, 2:38 p.m. ]

Date of Adoption: October 16, 2000.

Purpose: To comply with the Governor's Executive Order 97-02 on regulatory reform, and to ensure that current policy is reflected in rule.

Citation of Existing Rules Affected by this Order: Amending WAC 388-526-2610.

Statutory Authority for Adoption: RCW 74.08.090, 34.05.060.

Adopted under notice filed as WSR 00-17-164 on August 22, 2000.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0. Effective Date of Rule: Thirty-one days after filing.

October 16, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

2781.4
AMENDATORY SECTION(Amending Order 3732, filed 5/3/94, effective 6/3/94)

WAC 388-526-2610
Prehearing reviews for clients who request a fair hearing((s)).

(1) A client ((aggrieved by a department decision shall have a right to a fair hearing as provided under chapter 388-08 WAC.

(2) Medical assistance administration shall be responsible for a prehearing review when the fair hearing request questions a decision:

(a) Of a medical consultant; or

(b) Concerning an eligibility determination in the Medicaid category or state-funded medical program.

(3) Medical assistance administration shall review all fair hearing requests referred by the fair hearing coordinator to determine whether or not the:

(a) Appellant's request for service was filed according to the applicable rules and regulations;

(b) Decision has been made upon complete and accurate evaluation of the facts, existing standards, regulations, and policies.

(4) All records and information necessary to determine the validity of the appellant's fair hearing request on request to the reviewing authority and forwarded not later than ten days from such request.

(5) The examiner or the appellant may obtain a medical assessment by a professionally qualified person not a party to the action being appealed, at the request of the examiner or the appellant.

(6) On receipt of the necessary material, evidence, or reports, the designated reviewing authority shall evaluate the appellant's request in accord with existing rules, regulations, and policies of the department. The reviewing authority may:

(a) Reverse the decision when such adverse decision has been made contrary to the rules, regulations and policies of medical assistance administration;

(b) Resolve a situation resulting in the fair hearing request by adjustment.

(7) In providing a system for fair hearings for medical care clients, the department shall follow the rules in chapter 388-08 WAC and, where appropriate, other portions of the rules which are applicable to the particular circumstances of the appellant)) who does not agree with a department decision regarding medical or dental services has a right to a fair hearing under chapter 388-02 WAC.

(a) See chapter 388-538 WAC for hearing requests regarding managed care plans;

(b) See chapter 388-542 WAC for hearing requests regarding the children's health insurance program (CHIP);

(c) See WAC 388-502-0165 for requests for noncovered services.

(2) When a fair hearing is requested, either the client or MAA has the right to request and the client receive a medical assessment appropriate to the nature of the decision from one or more professionally qualified persons who are not a party to the action being appealed. WAC 388-538-120 applies to clients who are managed care enrollees.

(3) After receiving a request for a fair hearing, MAA may request additional information from the client, the provider, or the department. After MAA reviews the available information, the result may be:

(a) A reversal of the initial department decision;

(b) Resolution of the client's issue(s); or

(c) A fair hearing conducted per chapter 388-02 WAC.

[Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), 388-526-2610, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-040.]

Washington State Code Reviser's Office