WSR 02-17-083

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed August 19, 2002, 4:21 p.m. ]

Original Notice.

Exempt from preproposal statement of inquiry under RCW 34.05.310(4).

Title of Rule: WAC 388-526-2610 MAA hearings for clients and 388-526-2620 MAA hearings for providers/vendors.

Purpose: MAA is instituting a process to review initial administrative hearing decisions in situations where a client, a provider, or MAA wishes to appeal the administrative law judge's initial decision. This process is being instituted because the DSHS board of appeals will no longer review MAA administrative hearing decisions.

Other Identifying Information: These rules are being proposed without prior filing of a CR-101, preproposal statement of inquiry. The proposed rules are exempt from filing a CR-101 notice under RCW 34.05.310 (4)(g)(i) "This section does not apply to... rules that adopt, amend or repeal... a procedure, practice or requirement relating to agency hearings."

Statutory Authority for Adoption: RCW 34.05.020, 34.05.461, 34.05.470, and 34.05.473.

Statute Being Implemented: RCW 34.05.020, 34.05.461, 34.05.470, and 34.05.473.

Summary: See Title of Rule above.

Reasons Supporting Proposal: The rules will maintain the option for clients, providers, and the agency to request a review of an administrative law judge's initial hearing decision.

Name of Agency Personnel Responsible for Drafting: Kevin Sullivan, P.O. Box 45503, 925 Plum Street, Olympia, WA 98504-5533, (360) 725-1344; Implementation and Enforcement: Evelyn J. Cantrell, P.O. Box 45503, 925 Plum Street, Olympia, WA 98504-5533, (360) 725-1254.

Name of Proponent: Department of Social and Health Services, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: MAA is instituting a process to review initial administrative hearing decisions in situations where a client, a provider, or MAA wishes to appeal the administrative law judge's (ALJ) initial decision. This process is being instituted because the DSHS board of appeals will no longer review MAA administrative hearing decisions. Will maintain the status quo wherein a client or a provider or the agency can request a review of an ALJ's hearing decision.

Proposal Changes the Following Existing Rules: See Title of Rule and Explanation of Rule above.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The proposed rule does not cause an economic impact on small businesses.

RCW 34.05.328 does not apply to this rule adoption. The proposed rule does not meet the definition of a significant legislative rule under RCW 34.05.328 (5)(c)(iii), which states, "Significant rules are rules other than a procedural or interpretive rule." The proposed rule is a procedural rule as defined in RCW 34.05.328 (5)(c)(i)(A), which states, "A procedural rule is a rule that... adopts, amends, or repeals any procedure, practice or requirement relating to any agency hearings."

Hearing Location: Blake Office Park (behind Goodyear Courtesy Tire), 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on September 24, 2002, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by September 20, 2002, phone (360) 664-6094, TTY (360) 664-6178, e-mail fernaax@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, e-mail fernaax@dshs.wa.gov, by 5:00 p.m., September 24, 2002.

Date of Intended Adoption: Not sooner than September 25, 2002.

August 16, 2002

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3159.1
AMENDATORY SECTION(Amending WSR 00-21-062, filed 10/16/00, effective 11/16/00)

WAC 388-526-2610   ((Prehearing reviews)) Medical assistance administration (MAA) hearings for clients ((who request a fair hearing)).   (1) A medical assistance administration (MAA) client who does not agree with ((a department decision regarding)) an MAA denial of medical ((or)), dental, or transportation services has a right to a fair hearing under chapter 388-02 WAC. All of the rules and definitions of that chapter apply except that:

(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)) A party may request that MAA review an initial order when a party disagrees with or wants a change in an initial order, other than correcting a clerical error;

(b) The process for requesting a review of an initial order is the same process set out in WAC 388-02-0560 to 388-02-0600, except that MAA performs the review and a party sends the request for review to MAA's assistant secretary:

Assistant Secretary

Medical Assistance Administration

Department of Social and Health Services

P.O. Box 45500

Olympia, WA 98504-5500

(c) The assistant secretary or its designee may review the request and enter a final order;

(d) The person reviewing the request for review will be termed the reviewing officer;

(e) The reviewing officer has the same decision-making authority as an administrative law judge (ALJ), but must consider that when the ALJ adjudicated the case the ALJ had an opportunity to observe the witnesses and determine whether their testimony was credible; and

(f) If a party does not agree with the final order, the party may request a reconsideration of the final order under WAC 388-02-0605 to 388-02-0635, except that the party must direct the request for reconsideration to the reviewing officer who issued the final order. The reviewing officer will reconsider the final order.

(2) See chapter 388-538 WAC for hearing requests regarding managed care plans, except that the exceptions in subsections (1)(a) through (f) of this section apply.

(3) See chapter 388-542 WAC for hearing requests regarding the state children's health insurance program (S-CHIP), except that the exceptions in subsections (1)(a) through (f) of this section apply.

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

(5) 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.

(6) 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, 34.05.060. 00-21-062, 388-526-2610, filed 10/16/00, effective 11/16/00. 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.]


NEW SECTION
WAC 388-526-2620   Medical assistance administration (MAA) hearings for providers or vendors.   A medical assistance administration (MAA) provider or vendor entitled to an administrative hearing under RCW 43.20B.675, except nursing homes under chapter 74.46 RCW, has a right to an administrative hearing under chapter 388-02 WAC except that:

(1) A party may request that MAA review an initial order when a party disagrees with or wants a change in an initial order, other than correcting a clerical error;

(2) The process for requesting a review of an initial order is the same process set out in WAC 388-02-0560 to 388-02-0600, except that MAA performs the review and a party sends the request for review to MAA's assistant secretary:

Assistant Secretary

Medical Assistance Administration

Department of Social and Health Services

P.O. Box 45500

Olympia, WA 98504-5500

(3) The assistant secretary or its designee may review the request and enter a final order;

(4) The person reviewing the request for review will be termed the reviewing officer;

(5) The reviewing officer has the same decision-making authority as an administrative law judge (ALJ), but must consider that when the ALJ adjudicated the case the ALJ had an opportunity to observe the witnesses and determine whether their testimony was credible; and

(6) If a party does not agree with the final order, the party may request a reconsideration of the final order under WAC 388-02-0605 to 388-02-0635, except that the party must direct the request for reconsideration to the reviewing officer who issued the final order. The reviewing officer will reconsider the final order.

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Washington State Code Reviser's Office