WSR 97-21-128

PERMANENT RULES

HEALTH CARE AUTHORITY

[Filed October 21, 1997, 11:40 a.m.]

Date of Adoption: October 21, 1997.

Purpose: Revision of the WAC to reflect current Health Care Authority policies.

Citation of Existing Rules Affected by this Order: Amending WAC 182-16-030, 182-16-040, and 182-16-050.

Statutory Authority for Adoption: RCW 41.05.160.

Adopted under notice filed as WSR 97-17-109 on August 20, 1997.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, amended 0, repealed 0; Federal Rules or Standards: New 0, amended 0, repealed 0; or Recently Enacted State Statutes: New 0, amended 0, repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, amended 0, repealed 0.

Number of Sections Adopted on the Agency's own Initiative: New 0, amended 3, repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, amended 3, repealed 0.

Number of Sections Adopted using Negotiated Rule Making: New 0, amended 0, repealed 0; Pilot Rule Making: New 0, amended 0, repealed 0; or Other Alternative Rule Making: New 0, amended 0, repealed 0.

Effective Date of Rule: Thirty-one days after filing.

October 21, 1997

Elin Meyer

Rules Coordinator

AMENDATORY SECTION (Amending WSR 91-14-025, filed 6/25/91, effective 7/26/91)

WAC 182-16-030 Appeals from agency decisions--Applicability. Any enrollee of ((a)) the health care ((authority-administered)) authority's administered insurance plans (the self-insured plans) aggrieved by a decision of the agency or its agent concerning any matter related to scope of coverage, denials of claims, determinations of eligibility, or cancellations or nonrenewals of coverage may obtain administrative review of such decision by filing a notice of appeal with the ((administrator of the)) health care authority's appeals committee. Review of decisions made by HMOs or similar health care contractors will be pursuant to the grievance/arbitration provisions of those plans and are not subject to these rules. Except that decisions concerning eligibility determinations are reviewable only by the health care authority.

[Statutory Authority: RCW 41.05.010 and 34.05.250. 91-14-025, 182-16-030, filed 6/25/91, effective 7/26/91.]

AMENDATORY SECTION (Amending WSR 91-14-025, filed 6/25/91, effective 7/26/91)

WAC 182-16-040 Appeals--Notice of appeal contents. Any person aggrieved by a decision of the health care authority may appeal that decision by filing a notice of appeal with the ((administrator)) health care authority's appeals committee. The notice of appeal must contain:

(1) The name and mailing address of the enrollee;

(2) The name and mailing address of the appealing party;

(3) The name and mailing address of the appealing party's representative, if any;

(4) A statement identifying the specific portion of the decision being appealed ((from and that portion of the decision considered unjust or unlawful)) making it clear what it is that is believed to be unlawful or unjust;

(5) A clear and concise statement of facts in support of appealing party's position;

(6) ((A statement indicating whether the aggrieved person desires a hearing;

(7))) Any and all information or documentation that the aggrieved person would like considered and feels substantiates why the claim or request for coverage should be covered (information or documentation submitted at a later date, unless specifically requested by the appeals committee, may not be considered in the appeal decision);

(7) A copy of the plan's response to the issue the appellant has raised;

(8) The type of relief sought;

(((8))) (9) A statement that the appealing party has read the notice of appeal and believes the contents to be true, followed by his/her signature and the signature of his/her representative, if any;

(((9))) (10) The appealing party shall file, personally or by mail, with the health care authority the original ((and two copies of the)) notice of appeal. The notice of appeal must be received by the health care authority within sixty days after the decision of the agency staff was mailed to the appealing party. The agency shall acknowledge receipt of the copies filed with the agency ((and the agency's stamp placed upon such copies shall be prima facie evidence of the date of receipt));

(((10))) (11) Within thirty days after receipt of notice of appeal, the agency shall notify the appellant of any obvious errors or omissions, and request any additional information.

(12) The appeals committee will render a written decision within sixty days of receipt of the appeal.

[Statutory Authority: RCW 41.05.010 and 34.05.250. 91-14-025, 182-16-040, filed 6/25/91, effective 7/26/91.]

AMENDATORY SECTION (Amending WSR 91-14-025, filed 6/25/91, effective 7/26/91)

WAC 182-16-050 Appeals--Hearings. (1) ((If, in his/her notice of appeal, the person aggrieved does not request a hearing on the matter, the administrator or his/her designee shall consider all information submitted by the parties and render a decision which shall be deemed the final decision of the agency. A copy of that decision accompanied by a written statement of the reasons for the decision shall be served upon the enrollee or person aggrieved and the agency staff or agent who rendered the decision appealed from.)) If the health care authority's appeals committee upholds the original denial, the enrollee may request a hearing by writing to the health care authority's appeals manager. The health care authority must receive the written request for a hearing within fifteen days of the date the appeals committee's decision was mailed to the appellant.

(2) ((If, in his/her notice of appeal the person aggrieved requests a hearing,)) The agency shall set the time and place of the hearing and give not less than seven days notice to all parties and persons who have filed written petitions to intervene.

(3) The administrator or his/her designee shall preside at all hearings resulting from the filings of appeals.

(4) All hearings shall be conducted in compliance with these rules, chapter 34.05 RCW and chapter 10-08 WAC as applicable.

(5) ((Following completion)) Within ninety days of the hearing, the administrator or his/her designee shall render a decision which shall be the final decision of the agency. A copy of that decision accompanied by a written statement of the reasons for the decision shall be served on all parties and persons who have intervened.