PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 99-05-044.
Title of Rule: Amending WAC 388-526-2610 Fair hearings (new title "Prehearing reviews for clients who request a fair hearing").
Purpose: To comply with the Governor's Executive Order 97-02 on regulatory reform which mandates that rules be reviewed for clarity, fairness, necessity, etc. To ensure that current department policy and practice is accurately reflected in rule.
Statutory Authority for Adoption: RCW 74.08.090, 34.05.060.
Statute Being Implemented: RCW 34.05.060.
Summary: The proposed rule codifies the informal, prehearing review process that the department may use in attempting to settle a dispute with a client who, disagreeing with a medical decision made by the department, has requested a fair hearing.
Reasons Supporting Proposal: To comply with the Governor's Executive Order 97-02. To ensure that department policy and practice is accurately reflected in rule.
Name of Agency Personnel Responsible for Drafting: Ann Myers, DPS/RIP, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1345; and Implementation: Edwina Dorsey, DOSS/ASAS, P.O. Box 45503, Olympia, WA 98504-5503, (360) 725-1249.
Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.
Rule is not necessitated by federal law, federal or state court decision.
Explanation of Rule, its Purpose, and Anticipated Effects: The proposed rule clearly states the informal, prehearing review process the department may use to resolve client issues when the client who disagrees with a medical decision made by the department has requested a fair hearing regarding that decision.
The purpose of the rule is to inform clients of the informal, prehearing settlement process that is available when they request a fair hearing regarding a medical decision made by the department.
The anticipated effect is to make the process easy for the client to understand and use.
Proposal Changes the Following Existing Rules: The rule clarifies language in the current rule so that the client prehearing review process is easier to understand, and updates the process so it accurately reflects department policy and practice.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rule and concludes that because current policy is not being changed, no new costs will be imposed on the businesses affected by the rule. Therefore, no economic impact statement is necessary.
RCW 34.05.328 does not apply to this rule adoption. The department has analyzed the proposed rule and concludes that it does not meet the definition of a "significant legislative rule."
Hearing Location: Blake Office Building East, 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on October 3, 2000, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Kelly Cooper, Rules Coordinator, by September 26, 2000, phone (360) 664-6094, TTY (360) 664-6178, e-mail coopeKD@dshs.wa.gov.
Submit Written Comments to: Identify WAC Numbers, Kelly Cooper, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by October 3, 2000.
Date of Intended Adoption: No sooner than October 4, 2000.
August 17, 2000
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit
2781.4
(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.]