Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-538 - Managed care
Section 182-538-110 - The grievance and appeal system and agency administrative hearing for managed care organization (MCO) enrollees
Universal Citation: WA Admin Code 182-538-110
Current through Register Vol. 24-18, September 15, 2024
(1) Introduction. This section contains information about the grievance and appeal system and the right to an agency administrative hearing for MCO enrollees. See WAC 182-538-111 for information about PCCM enrollees.
(2) Statutory basis and framework.
(a) Each MCO must have a
grievance and appeal system in place for enrollees.
(b) Once an MCO enrollee has completed the
MCO appeals process, the MCO enrollee has the option of requesting an agency
administrative hearing regarding any adverse benefit determination upheld by
the MCO. See chapter 182-526 WAC.
(3) MCO grievance and appeal system - General requirements.
(a) The MCO
grievance and appeal system must include:
(i)
A process for addressing complaints about any matter that is not an adverse
benefit determination, which is a grievance;
(ii) An appeal process to address enrollee
requests for review of an MCO adverse benefit determination; and
(iii) Access to the agency's administrative
hearing process for review of an MCO's resolution of an appeal.
(b) MCOs must provide information
describing the MCO's grievance and appeal system to all providers and
subcontractors.
(c) An MCO must
have agency approval for written materials sent to enrollees regarding the
grievance and appeal system and the agency's administrative hearing process
under chapter 182-526 WAC.
(d) MCOs
must inform enrollees in writing within fifteen calendar days of enrollment
about enrollees' rights with instructions on how to use the MCO's grievance and
appeal system and the agency's administrative hearing process.
(e) An MCO must give enrollees any reasonable
assistance in completing forms and other procedural steps for grievances and
appeals (e.g., interpreter services and toll-free numbers).
(f) An MCO must allow enrollees and their
authorized representatives to file grievances and appeals orally as well as in
writing.
(g) Methods to file either
a grievance or appeal include, but are not limited to, U.S. mail, commercial
delivery services, hand delivery, fax, telephone, and email.
(h) MCOs may not require enrollees to provide
written follow-up for a grievance the MCO received orally.
(i) The MCO must resolve each grievance and
appeal and provide notice of the resolution as expeditiously as the enrollee's
health condition requires, and within the time frames identified in this
section.
(j) The MCO must ensure
that the people who make decisions on grievances and appeals:
(i) Neither were involved in any previous
level of review or decision making, nor a subordinate of any person who was so
involved; and
(ii) Are health care
professionals with appropriate clinical expertise in treating the enrollee's
condition or disease if deciding any of the following:
(A) An appeal of an adverse benefit
determination concerning medical necessity;
(B) A grievance concerning denial of an
expedited resolution of an appeal; or
(C) A grievance or appeal that involves any
clinical issues.
(iii)
Take into account all comments, documents, records, and other information
submitted by the enrollee or the enrollee's representative without regard to
whether the information was submitted or considered in the initial adverse
benefit determination.
(4) The MCO grievance process.
(a) Only an enrollee or enrollee's authorized
representative may file a grievance with the MCO. A provider may not file a
grievance on behalf of an enrollee without the enrollee's written
consent.
(b) The MCO must
acknowledge receipt of each grievance within two business days. Acknowledgment
may be orally or in writing.
(c)
The MCO must complete the resolution of a grievance and provide notice to the
affected parties as expeditiously as the enrollee's health condition requires,
but no later than forty-five days after receiving the grievance.
(d) The MCO must notify enrollees of the
resolution of grievances within five business days of determination.
(i) Notices of resolution of grievances not
involving clinical issues can be oral or in writing.
(ii) Notices of resolution of grievances for
clinical issues must be in writing.
(e) Enrollees do not have a right to an
agency administrative hearing to dispute the resolution of a grievance unless
the MCO fails to adhere to the notice and timing requirements for
grievances.
(f) If the MCO fails to
adhere to the notice and timing requirements for grievances, the enrollee is
deemed to have completed the MCO's appeals process and may initiate an agency
administrative hearing.
(5) MCO's notice of adverse benefit determination.
(a)
Language and
format requirements. The notice of adverse benefit determination must be
in writing in the enrollee's primary language, and in an easily understood
format, in accordance with 42 C.F.R. Sec. 438.404.
(b)
Content of notice. The
notice of MCO adverse benefit determination must explain:
(i) The adverse benefit determination the MCO
has made or intends to make, and any pertinent effective date;
(ii) The reasons for the adverse benefit
determination, including citation to rules or regulations and the MCO criteria
that were the basis of the decision;
(iii) The enrollee's right to receive upon
request, free of charge, reasonable access to and copies of all documents,
records, and other information relevant to the enrollee's adverse benefit
determination, including medical necessity criteria and any processes,
strategies, or evidentiary standards used in setting coverage limits;
(iv) The enrollee's right to file an appeal
of the MCO adverse benefit determination, including information on the MCO
appeal process and the right to request an agency administrative
hearing;
(v) The procedures for
exercising the enrollee's rights;
(vi) The circumstances under which an appeal
can be expedited and how to request it;
(vii) The enrollee's right to have benefits
continued pending resolution of an appeal, how to request that benefits be
continued, and the circumstances under which the enrollee may be required to
pay the costs of these services.
(c)
Timing of notice. The MCO
must mail the notice of adverse benefit determination within the following time
frames:
(i) For termination, suspension, or
reduction of previously authorized services, at least ten calendar days prior
to the effective date of the adverse benefit determination in accordance with
42 C.F.R. Sec. 438.404 and 431.211. This time period does not apply if the
criteria in 42 C.F.R. Sec. 431.213 or 431.214 are met. This notice must be
mailed by a method that certifies receipt and assures delivery within three
calendar days.
(ii) For denial of
payment, at the time of any adverse benefit determination affecting the claim.
This applies only when the enrollee can be held liable for the costs associated
with the adverse benefit determination.
(iii) For standard service authorization
decisions that deny or limit services, as expeditiously as the enrollee's
health condition requires not to exceed fourteen calendar days following
receipt of the request for service. An extension of up to fourteen additional
days may be allowed if:
(A) The enrollee or
enrollee's provider requests the extension.
(B) The MCO determines and justifies to the
agency upon request, a need for additional information and that the extension
is in the enrollee's interest.
(iv) If the MCO extends the time frame for
standard service authorization decisions, the MCO must:
(A) Give the enrollee written notice of the
reason for the decision to extend and inform the enrollee of the right to file
a grievance if the enrollee disagrees with that decision; and
(B) Issue and carry out its determination as
expeditiously as the enrollee's health condition requires and no later than the
date the extension expires.
(v) For expedited authorization decisions:
(A) In cases involving mental health drug
authorization decisions, or where the provider indicates or the MCO determines
that following the standard time frame could seriously jeopardize the
enrollee's life or health or ability to attain, maintain, or regain maximum
function, the MCO must make an expedited authorization decision and provide
notice no later than seventy-two hours after receipt of the request for
service.
(B) The MCO may extend the
seventy-two-hour time frame up to fourteen calendar days if:
(I) The enrollee requests the extension;
or
(II) The MCO determines and
justifies to the agency, upon request, there is a need for additional
information and it is in the enrollee's interest.
(6) The MCO appeal process.
(a)
Authority to appeal. An enrollee, the enrollee's authorized
representative, or the provider acting with the enrollee's written consent may
appeal an adverse benefit determination from the MCO.
(b)
Oral appeals. An MCO must
treat oral inquiries about appealing an adverse benefit determination as an
appeal to establish the earliest possible filing date for the appeal. The oral
appeal must be confirmed in writing by the MCO, unless the enrollee or provider
requests an expedited resolution.
(c)
Acknowledgment letter. The
MCO must acknowledge in writing receipt of each appeal to both the enrollee and
the requesting provider within five calendar days of receiving the appeal
request. The appeal acknowledgment letter sent by the MCO serves as written
confirmation of an appeal filed orally by an enrollee.
(d)
Standard service authorization -
Sixty-day deadline. For appeals involving standard service authorization
decisions, an enrollee must file an appeal within sixty calendar days of the
date on the MCO's notice of adverse benefit determination. This time frame also
applies to a request for an expedited appeal.
(e)
Previously authorized service -
Ten-day deadline. For appeals of adverse benefit determinations
involving termination, suspension, or reduction of a previously authorized
service, and the enrollee is requesting continuation of the service, the
enrollee must file an appeal within ten calendar days of the MCO mailing notice
of the adverse benefit determination.
(f)
Untimely service authorization
decisions. When the MCO does not make a service authorization
decision within required time frames, it is considered a denial. In this
case, the MCO sends a formal notice of adverse benefit determination, including
the enrollee's right to an appeal.
(g)
Appeal process requirements.
The MCO appeal process must:
(i) Provide the
enrollee a reasonable opportunity to present evidence and allegations of fact
or law, in person, by telephone, or in writing. The MCO must inform the
enrollee of the limited time available for this in the case of expedited
resolution;
(ii) Provide the
enrollee and the enrollee's representative opportunity before and during the
appeal process to examine the enrollee's case file, including medical records,
other relevant documents and records, and any new or additional evidence
considered, relied upon, or generated by the MCO (or at the direction of the
MCO) in connection with the appeal of the adverse benefit determination. This
information must be provided free of charge and sufficiently in advance of the
resolution time frame for appeals as specified in this section; and
(iii) Include as parties to the appeal:
(A) The enrollee and the enrollee's
representative; or
(B) The legal
representative of the deceased enrollee's estate.
(h)
Level of appeal.
There will only be one level of review in the MCO appeals process.
(i) Time frames for resolution of appeals and
notice to the enrollee. MCOs must resolve each appeal and provide notice as
expeditiously as the enrollee's health condition requires, and within the
following time frames:
(i) For standard
resolution of appeals, including notice to the affected parties, no longer than
thirty calendar days from the day the MCO receives the appeal. This includes
appeals involving termination, suspension, or reduction of previously
authorized services.
(ii) For
expedited resolution of appeals, including notice to the affected parties, no
longer than seventy-two hours after the MCO receives the appeal. The MCO may
extend the seventy-two-hour time frame up to fourteen calendar days if:
(A) The enrollee requests the extension;
or
(B) The MCO determines and shows
to the satisfaction of the agency, upon request, there is a need for additional
information and it is in the enrollee's interest.
(iii) If the MCO fails to adhere to the
notice and timing requirements for appeals, the enrollee is deemed to have
completed the MCO's appeals process and may request an agency administrative
hearing.
(j)
Language and format requirements - Notice of resolution of appeal.
(i) The notice of the resolution of the
appeal must be in writing in the enrollee's primary language and in an easily
understood format, in accordance with 42 C.F.R. Sec. 438.10.
(ii) The notice of the resolution of the
appeal must be sent to the enrollee and the requesting provider.
(iii) For notice of an expedited resolution,
the MCO must also make reasonable efforts to provide oral notice.
(k)
Content of resolution of
appeal.
(i) The notice of resolution
must include the results of the resolution process and the date it was
completed;
(ii) For appeals not
resolved wholly in favor of the enrollee, the notice of resolution must
include:
(A) The right to request an agency
administrative hearing under
RCW
74.09.741 and chapter 182-526 WAC, and how to
request the hearing;
(B) The right
to request and receive benefits while an agency administrative hearing is
pending, and how to make the request in accordance with subsection (9) of this
section and the agency's administrative hearing rules in chapter 182-526
WAC;
(C) That the enrollee may be
held liable for the cost of those benefits received for the first sixty days
after the agency or the office of administrative hearings (OAH) receives an
agency administrative hearing request, if the hearing decision upholds the
MCO's adverse benefit determination. See
RCW
74.09.741(5)(g).
(7) MCO expedited appeal process.
(a)
Each MCO must establish and maintain an expedited appeal process when the MCO
determines or the provider indicates that taking the time for a standard
resolution of an appeal could seriously jeopardize the enrollee's life,
physical or mental health, or ability to attain, maintain, or regain maximum
function.
(b) The enrollee may file
an expedited appeal either orally, according to WAC
182-526-0095,
or in writing. No additional follow-up is required of the enrollee.
(c) The MCO must make a decision on the
enrollee's request for expedited appeal and provide written notice as
expeditiously as the enrollee's health condition requires and no later than two
calendar days after the MCO receives the appeal. The MCO must also make
reasonable efforts to orally notify the enrollee of the decision.
(d) The MCO may extend the time frame for
decision on the enrollee's request for an expedited appeal up to fourteen
calendar days if:
(i) The enrollee requests
the extension; or
(ii) The MCO
determines and shows to the satisfaction of the agency, upon its request, that
there is a need for additional information and the delay is in the enrollee's
interest.
(e) The MCO
must make reasonable efforts to provide the enrollee prompt verbal notice and
provide written notice for any extension not requested by the enrollee with the
reason for the delay.
(f) If the
MCO grants an expedited appeal, the MCO must issue a decision as expeditiously
as the enrollee's physical or mental health condition requires, but not later
than seventy-two hours after receiving the appeal. The MCO may extend the time
frame for a decision and to provide notice to the enrollee for an expedited
appeal, up to fourteen days, if:
(i) The
enrollee requests the extension; or
(ii) The MCO determines and shows to the satisfaction of the
agency, upon its request, that there is a need for additional information and
the delay is in the enrollee's interest.
(g) The MCO must provide written notice for
any extension not requested by the enrollee within two calendar days of the
decision and inform the enrollee of the reason for the delay and the enrollee's
right to file a grievance.
(h) If
the MCO denies a request for expedited resolution of an appeal, it must:
(i) Process the appeal based on the time
frame for standard resolution;
(ii)
Make reasonable efforts to give the enrollee prompt oral notice of the denial;
and
(iii) Provide written notice
within two calendar days.
(i) The MCO must ensure that punitive action
is not taken against a provider who requests an expedited resolution or
supports an enrollee's appeal.
(8) The right to an agency administrative hearing for managed care (MCO) enrollees.
(a)
Authority to file. Only an
enrollee, the enrollee's authorized representative, or a provider with the
enrollee's or authorized representative's written consent may request an
administrative hearing. See
RCW
74.09.741, WAC
182-526-0090,
and
182-526-0155.
(b)
Right to agency administrative
hearing. If an enrollee has completed the MCO appeal process and does
not agree with the MCO's resolution of the appeal, the enrollee may file a
request for an agency administrative hearing based on the rules in this section
and the agency administrative hearing rules in chapter 182-526 WAC.
(c)
Deadline - One hundred twenty
days. An enrollee's request for an agency administrative hearing must be
filed no later than one hundred twenty calendar days from the date of the
written notice of resolution of appeal from the MCO.
(d)
Independent party. The MCO
is an independent party and responsible for its own representation in any
agency administrative hearing, appeal to the board of appeals, and any
subsequent judicial proceedings.
(e)
Applicable rules. The
agency's administrative hearing rules in chapter 182-526 WAC apply to agency
administrative hearings requested by enrollees to review the resolution of an
enrollee appeal of an MCO adverse benefit determination.
(9) Continuation of previously authorized services.
(a) The MCO must
continue the enrollee's services if all of the following apply:
(i) The enrollee, or enrollee's authorized
representative, or provider with written consent files the appeal on or before
the later of the following:
(A) Within ten
calendar days of the MCO mailing the notice of adverse benefit determination;
or
(B) The intended effective date
of the MCO's proposed adverse benefit determination.
(ii) The appeal involves the termination,
suspension, or reduction of previously authorized services;
(iii) The services were ordered by an
authorized provider; and
(iv) The
original period covered by the original authorization has not
expired.
(b) If the MCO
continues or reinstates the enrollee's services while the appeal is pending at
the enrollee's request, the services must be continued until one of the
following occurs:
(i) The enrollee withdraws
the MCO appeal;
(ii) The enrollee
fails to request an agency administrative hearing within ten calendar days
after the MCO sends the notice of an adverse resolution to the enrollee's
appeal;
(iii) The enrollee
withdraws the request for an agency administrative hearing; or
(iv) The office of administrative hearings
(OAH) issues a hearing decision adverse to the enrollee.
(c) If the final resolution of the appeal
upholds the MCO's adverse benefit determination, the MCO may recover from the
enrollee the amount paid for the services provided to the enrollee for the
first sixty calendar days after the agency or the office of administrative
hearings (OAH) received a request for an agency administrative hearing, to the
extent that services were provided solely because of the requirement for
continuation of services.
(10) Effect of reversed resolutions of appeals.
(a)
Services not
furnished while an appeal is pending. If the MCO or a final order
entered by the HCA board of appeals, as defined in chapter 182-526 WAC, or an
independent review organization (IRO) reverses a decision to deny, limit, or
delay services that were not provided while the appeal was pending, the MCO
must authorize or provide the disputed services promptly, and as expeditiously
as the enrollee's health condition requires, but not later than seventy-two
hours from the date it receives notice reversing the determination.
(b)
Services furnished while the appeal
is pending. If the MCO reverses a decision to deny authorization of
services or the denial is reversed through an IRO or a final order of OAH or
the board of appeals and the enrollee received the disputed services while the
appeal was pending, the MCO must pay for those services.
Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. 13-02-010, §182-538-110, filed 12/19/12, effective 2/1/13. 11-14-075, recodified as §182-538-110, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. 08-15-110, § 388-538-110, filed 7/18/08, effective 8/18/08; 06-03-081, § 388-538-110, filed 1/12/06, effective 2/12/06; 03-18-110, § 388-538-110, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510,[74.08.]522 , 74.09.450, 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-538-110, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396(a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-110, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090. 97-04-004, § 388-538-110, filed 1/24/97, effective 2/24/97. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-110, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. 94-04-038 (Order 3701), § 388-538-110, filed 1/26/94, effective 2/26/94; 93-17-039 (Order 3621), § 388-538-110, filed 8/11/93, effective 9/11/93.
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