HEALTH CARE AUTHORITY

(Medicaid Program)

(a) The agency determines that:

(i) There is a quality of care issue with significant risk factors that may endanger client health and/or safety (see WAC 182-502-0030 (1)(a)); or

(ii) There are risk factors that affect the credibility, honesty, or veracity of the health care practitioner (see WAC 182-502-0030 (1)(b)).

(b) The health care professional, health care entity, supplier or contractor of service:

(i) Is excluded from participation in medicare, medicaid or any other federally funded health care program;

(ii) Has a current formal or informal pending disciplinary action, statement of charges, or the equivalent from any state or federal professional disciplinary body at the time of initial application;

(iii) ((Has been disciplined based on allegation of sexual misconduct or admitted to sexual misconduct;

(iv))) Has a suspended, terminated, revoked, or surrendered professional license as defined under chapter 18.130 RCW;

(((v))) (iv) Has a restricted, suspended, terminated, revoked, or surrendered professional license in any state;

(((vi))) (v) Is noncompliant with the department of health's or other state health care agency's stipulation of informal disposition, agreed order, final order, or similar licensure restriction;

(((vii))) (vi) Is suspended or terminated by any agency within the state of Washington that arranges for the provision of health care;

(((viii))) (vii) Fails a background check, including a fingerprint-based criminal background check, performed by the agency. See WAC 182-502-0014 and 182-502-0016;

(((ix))) (viii) Does not have sufficient liability insurance according to WAC 182-502-0016 for the scope of practice; or

(((x))) (ix) Fails to meet the requirements of a site visit, as required by 42 C.F.R. 455.432.

(2) The agency may not pay for any health care service, drug, supply or equipment prescribed or ordered by a health care professional, health care entity, supplier or contractor of service whose application for a core provider agreement (CPA) has been denied or terminated.

(3) The agency may not pay for any health care service, drug, supply, or equipment prescribed or ordered by a health care professional, health care entity, supplier or contractor of service who does not have a current CPA with the agency when the agency determines there is a potential danger to a client's health and/or safety.

(4) Nothing in this chapter precludes the agency from entering into other forms of written agreements with a health care professional, health care entity, supplier or contractor of service.

(5) If the agency denies an enrollment application, the applicant does not have any dispute rights within the agency.

(6) Under 42 C.F.R. 455.470, the agency:

(a) Will impose a temporary moratorium on enrollment when directed by CMS; or

(b) May initiate and impose a temporary moratorium on enrollment when approved by CMS.

(1) In order for the ((department)) agency to review a decision previously made by the ((department)) agency, a provider must submit the request to review the decision:

(a) Within twenty-eight calendar days of the date on the ((department's)) agency's decision notice;

(b) To the address listed in the decision notice; and

(c) In a manner that provides proof of receipt.

(2) A provider's dispute request must:

(a) Be in writing;

(b) Specify the ((department)) agency decision that the provider is disputing;

(c) State the basis for disputing the ((department's)) agency's decision; and

(d) Include documentation to support the provider's position.

(3) The ((department)) agency may request additional information or documentation. The provider must submit the additional information or documentation to the ((department)) agency within twenty-eight calendar days of the date on the ((department's)) agency's request.

(4) The ((department)) agency closes the dispute without issuing a decision and with no right to further review under subsection (6) of this section when the provider:

(a) Fails to comply with any requirement of subsections (2), (3), and (4) of this section;

(b) Fails to cooperate with, or unduly delays, the dispute process; or

(c) Withdraws the dispute request in writing.

(5) The ((department)) agency will send the provider a written notice of dispute closure or written dispute decision.

(6) The provider may request the ((deputy assistant secretary of the medicaid purchasing administration (MPA))) director of the health care authority or designee to review the written dispute decision according to the process in WAC ((388-502-0270)) 182-502-0270.

(7) This section does not apply to disputes regarding overpayment. For disputes regarding overpayment, see WAC ((388-502-0230)) 182-502-0230.

(2) ((Providers who are denied enrollment or removed from participation due to sexual misconduct as defined in chapter 246-16 WAC or in profession-specific rules of the department of health (DOH) are not eligible to be enrolled for participation with the department.

(3))) Providers who are denied enrollment or removed from participation more than once are not eligible to reapply for participation with the ((department)) agency.

(2) Providers and former providers may request a review of ((a department)) an agency dispute decision. The request must be in writing and sent to: ((HRSA)) Health Care Authority, Attn: ((Deputy Assistant Secretary)) Appeals Administrator, P.O. Box 45504, Olympia, WA 98504-5504. The ((department)) agency must receive the written dispute review request within twenty-eight calendar days of the date on the ((department's)) agency's written dispute decision.

(3) When the ((department)) agency receives a timely dispute review request, the ((deputy)) director or designee may schedule a dispute review conference. "Dispute review conference" means an informal conference for the purpose of resolving disagreements between the ((department)) agency and a provider or former provider who is dissatisfied with ((a department)) an agency decision. The dispute review conference is not governed by the Administrative Procedure Act, chapter 34.05 RCW. If the ((deputy)) director or designee chooses to schedule a dispute review conference, the ((deputy)) director or designee will conduct the conference within ninety calendar days of the dispute review request unless the ((deputy)) director or designee and the party requesting review agree to an extension.

(4) The ((deputy)) director or designee will issue a dispute review decision to the provider or former provider requesting review within thirty calendar days of receiving the dispute review request or within thirty calendar days of the dispute review conference, whichever is later, unless both parties agree to an extension.

(5) The ((deputy)) director review is the final level of ((department)) agency review for disputes to which this section applies.