Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-538C - Crisis and noncrisis behavioral health services
Section 182-538C-110 - Grievance and appeal system and agency administrative hearing for behavioral health administrative services organizations (BH-ASOs)
Universal Citation: WA Admin Code 182-538C-110
Current through Register Vol. 24-18, September 15, 2024
(1) General. This section applies to the behavioral health administrative service organization (BH-ASO) grievance system for people within integrated managed care (IMC) regional service areas.
(a) The BH-ASO must have a grievance and
appeal system to allow a person to file a grievance and request a review of a
BH-ASO action as defined in this chapter.
(b) The agency's administrative hearing rules
in chapter 182-526 WAC apply to agency administrative hearings requested by a
person to review the resolution of an appeal of a BH-ASO action.
(c) If a conflict exists between the
requirements of this chapter and other rules, the requirements of this chapter
take precedence.
(d) The BH-ASO
must maintain records of grievances and appeals.
(e) The BH-ASO is not obligated to continue
services pending the results of an appeal or subsequent agency administrative
hearing.
(2) The BH-ASO grievance and appeal system. The BH-ASO grievance system includes:
(a) A process for addressing
complaints about any matter that is not an action;
(b) An appeal process to address a person's
request for a review of a BH-ASO action as defined in this chapter;
and
(c) Access to the agency's
administrative hearing process for a person to request a review of a BH-ASO's
resolution of an appeal.
(3) The BH-ASO grievance process.
(a) A person or a person's
authorized representative may file a grievance with a BH-ASO. A provider may
not file a grievance on behalf of a person without the written consent of the
person or the person's authorized representative.
(b) There is no right to an agency
administrative hearing regarding the BH-ASO's decision on a grievance, since a
grievance is not an action.
(c) The
BH-ASO must notify a person of the decision regarding the person's grievance
within five business days of the decision.
(4) The BH-ASO appeal process.
(a) Parties to the appeal include:
(i) The person and the person's authorized or
legal representative; or
(ii) The
authorized representative of the deceased person's estate.
(b) A person, the person's authorized
representative, or the provider acting with the person's written consent may
appeal a BH-ASO action.
(c) A
BH-ASO must treat oral inquiries about appealing an action as an appeal in
order to establish the earliest possible filing date for the appeal.
(d) The BH-ASO must confirm any oral appeal
in writing to the person or provider acting on behalf of the person.
(e) The person or provider acting on behalf
of the person must file an appeal, either orally or in writing, within sixty
calendar days of the date on the BH-ASO's notice of action.
(f) The BH-ASO must acknowledge receipt of
each appeal to both the person and the provider requesting the service within
three calendar days of receipt.
(g)
If the person requests an expedited appeal for a crisis-related service, the
BH-ASO must make a decision on whether to grant the person's request for
expedited appeal and provide written notice as expeditiously as the person's
health condition requires, within three calendar days after the BH-ASO receives
the appeal. The BH-ASO must make reasonable efforts to provide oral
notice.
(h) The BH-ASO appeal
process:
(i) Provides the person a reasonable
opportunity to present evidence and allegations of fact or law in
writing.
(ii) Provides the person
and the person's authorized representative opportunity before and during the
appeals process to examine the person's case file, including medical records
and any other documents and records considered during the appeal process free
of charge.
(iii) If the person
requests an expedited appeal, the BH-ASO must inform the person that it may
result in the person having limited time to review records and prepare for the
appeal.
(i) The BH-ASO
ensures the staff making decisions on appeals:
(i) Were not involved in any previous level
of review or decision making; and
(ii) Are health care professionals with
appropriate clinical expertise in treating the person's condition or disease if
deciding any of the following:
(A) An appeal
of an action; or
(B) An appeal that
involves any clinical issues.
(j) Time frames for standard resolution of
appeals.
(i) For appeals involving
termination, suspension, or reduction of previously authorized noncrisis
services, the BH-ASO must make a decision within fourteen calendar days after
receipt of the appeal.
(ii) If the
BH-ASO cannot resolve an appeal within fourteen calendar days, the BH-ASO must
notify the person that an extension is necessary to complete the
appeal.
(k) Time frames
for expedited appeals for crisis-related services.
(i) The BH-ASO must resolve the expedited
appeal and provide notice of the decision no later than three calendar days
after the BH-ASO receives the appeal.
(ii) The BH-ASO may extend the time frame by
fourteen additional calendar days if:
(A) The
person requests the extension; or
(B) The BH-ASO determines additional
information is needed and the delay is in the interests of the
person.
(iii) If the
BH-ASO denies a request for expedited resolution of a noncrisis related service
appeal, it must:
(A) Process the appeal based
on the time frame for standard resolution;
(B) Make reasonable efforts to give the
person prompt oral notice of the denial; and
(C) Follow-up within two calendar days of the
oral notice with a written notice of denial.
(l) Extension of a standard resolution or
expedited appeal not requested by the person.
(i) The BH-ASO must notify the person in
writing of the reason for the delay, if not requested by that person.
(ii) The extension cannot delay the decision
beyond twenty-eight calendar days of the request for appeal, without the
informed written consent of the person.
(m) Notice of resolution of appeal. The
notice of the resolution of the appeal must:
(i) Be in writing and be sent to the person
and the provider requesting the services;
(ii) Include the results of the resolution
process and the date it was completed; and
(iii) Include notice of the right to request
an agency administrative hearing and how to do so as provided in the agency
hearing rules in chapter 182-526 WAC, if the appeal is not resolved wholly in
favor of the person.
(5) Agency administrative hearings.
(a) Only a person or a
person's authorized representative may request an agency administrative
hearing. A provider may not request a hearing on behalf of a person.
(b) If a person does not agree with the
BH-ASO's resolution of an appeal, the person may file a request for an agency
administrative hearing based on this section and the agency hearing rules in
chapter 182-526 WAC.
(c) The BH-ASO
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.
(6) Effect of reversed resolutions of appeals. If the BH-ASO's decision not to provide services is reversed on appeal by the BH-ASO or through a final order from the agency administrative hearing process, the BH-ASO must authorize or provide the disputed services promptly and as expeditiously as the person's health condition requires.
(7) Available resources exhausted. When available resources are exhausted, any appeals or administrative hearing process related to a request for authorization of a noncrisis service will be terminated, since noncrisis services cannot be authorized without funding, regardless of medical necessity.
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