Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-557 - Health homes
Section 182-557-0350 - Health home-Grievance and appeals
Universal Citation: WA Admin Code 182-557-0350
Current through Register Vol. 24-18, September 15, 2024
(1) Qualified health homes must have a grievances and appeals process in place that complies with the requirements of this section and must maintain records of all grievances and appeals.
(a)This section contains information about
the grievance system for fee-for-service clients, including full dual eligible
clients, for health home services. These participants must follow the process
in chapter 182-526 WAC for appeals.
(b) Participants who are enrolled in an
agency-contracted managed care organization must follow the process in WAC
182-538-110 to file a grievance
or an appeal for health home services.
(2)Grievance process.
(a)Only a participant or the participant's
authorized representative may file a grievance with the qualified health home
orally or in writing. A health home care coordinator may not file a grievance
for the participant unless the participant gives the health home care
coordinator written consent to act on the participant's behalf.
(b)The qualified health home must:
(i) Accept, document, record, and process
grievances that it receives from the participant, the participant's
representative, or the agency;
(ii)
Acknowledge receipt of each grievance, either orally or in writing, within two
business days of receiving the grievance;
(iii) Assist the participant with all
grievance processes;
(iv) Cooperate
with any representative authorized in writing by the participant;
(v) Ensure that decision makers on grievances
were not involved in the activity or decision being grieved, or any review of
that activity or decision by qualified health home staff;
(vi) Consider all information submitted by
the participant or the participant's authorized representative;
(vii) Investigate and resolve all
grievances;
(viii) Complete the
disposition of a grievance and notice to the affected parties as quickly as the
participant's health condition requires, but no later than forty-five calendar
days from receipt of the grievance;
(ix) Notify the participant, either orally or
in writing, of the disposition of grievances within five business days of
determination. Notification must be in writing if the grievance is related to a
quality of care issue.
(3)Appeal process.
(a)The qualified health home must give the
participant written notice of an action.
(b)The written notice must:
(i) State what action the qualified health
home intends to take and the effective date of the action;
(ii) Explain the specific facts and reasons
for the decision to take the intended action;
(iii) Explain the specific rule or rules that
support the decision, or the specific change in federal or state law that
requires the action;
(iv) Explain
the participant's right to appeal the action according to chapter 182-526
WAC;
(v) State that the participant
must request a hearing within ninety calendar days from the date that the
notice of action is mailed.
(c) The qualified health home must send the
written notice to the participant no later than ten days before the date of
action. The written notice may be sent by the qualified health home no later
than the date of the action it describes only if:
(i) The qualified health home has factual
information confirming the death of a participant; or
(ii) The qualified health home receives a
written statement signed by a participant that:
(A) The participant no longer wishes to
receive health home services; or
(B) Provides information that requires
termination or reduction of health home services and which indicates that the
participant understands that supplying the information will result in health
home services being ended or reduced.
(d) A health home care coordinator may not
file an appeal for the participant.
(e)If the agency receives a request to appeal
an action of the qualified health home, the agency will provide the qualified
health home notice of the request.
(f) The agency will process the participant's
appeal in accordance with chapter 182-526 WAC.
(g) Continued coverage. If a participant
appeals an action by a qualified health home, the participant's health home
services will continue consistent with WAC
182-504-0130.
(h) Reinstated coverage. If the agency ends
or changes the participant's qualified health home coverage without advance
notice, the agency will reinstate coverage consistent with WAC
182-504-0135.
(i) If the participant requests a hearing,
the qualified health home must provide to the agency and the participant, upon
request, and within three working days, all documentation related to the
appeal.
(j) The qualified health
home is an independent party and is responsible for its own representation in
any administrative hearing, subsequent review process, and judicial
proceedings.
(k) If a final order,
as defined in WAC
182-526-0010, requires a
qualified health home to provide the participant health home services that were
not provided while the appeal was pending, the qualified health home must
authorize or provide the participant those health home services promptly. A
qualified health home cannot seek further review of a final order issued in a
participant's administrative appeal of an action taken by the qualified health
home.
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