Wash. Admin. Code § 388-877-0675 - Administrative hearings

(1) An administrative hearing (also known as "fair hearing") is a proceeding before an administrative law judge (ALJ) that gives an individual, as defined in WAC 388-877-0655, an opportunity to be heard in disputes about adverse benefit determinations or a decision of a behavioral health organization (BHO) to deny or limit authorization of a requested nonmedicaid service communicated on a notice of determination.

(2) An individual may request an administrative hearing for the following reasons:

(a) After an individual receives notice that the BHO upheld an adverse benefit determination;

(b) After an individual receives a BHO decision to deny or limit authorization of a requested nonmedicaid service communicated on a notice of determination; or

(c) If the BHO does not act within the grievance or appeal process time frames described in WAC 388-877-0660 and 388-877-0670. In this case, the individual is considered to have exhausted the appeal process and has a right to request an administrative hearing.

(3) An individual who requests an administrative hearing must do so within one of the following time frames:

(a) If continued services are not requested, a hearing must be requested within one hundred twenty calendar days from the date on the written notice of the resolution received from the BHO at the end of the appeal process or one hundred twenty calendar days from the date on the notice of determination.

(b) If continued medicaid services are requested pending the outcome of the administrative hearing, all of the following apply:

(i) The individual appealed a decision on the notice of adverse benefit determination for termination, suspension, or reduction of the individual's behavioral health services ;

(ii) The individual appealed the adverse benefit determination and the BHO upheld the adverse benefit determination; and

(iii) The individual requests an administrative hearing and continued behavioral health services within ten calendar days of the date on the written notification of the resolution.

(c) The BHO is not obligated to continue nonmedicaid services pending the result of an administrative hearing when available resources are exhausted, since services cannot be authorized without funding regardless of medical necessity.

(4) If an individual or the individual's behavioral health provider believes that the time taken for a standard administrative hearing could seriously jeopardize the individual's life, physical or mental health, or ability to attain, maintain, or regain maximum function, an expedited hearing may be requested. Subsection (3)(b) and (c) of this section applies if continued behavioral health services are requested.

(5) The BHO's failure to issue an appeal decision in writing within the time frames in WAC 388-877-0670 constitutes exhaustion of the appeal process and the individual may request an administrative hearing.

(6) When the criteria in this section are met for continued services, the BHO must continue the individual's behavioral health treatment services during the administrative hearing process until one of the following occurs:

(a) The individual withdraws the hearing request.

(b) The administrative law judge issues a hearing decision adverse to the individual.

(7) If the administrative hearing decision is not in favor of the individual, the BHO may recover the cost of the behavioral health services furnished to the individual while the hearing was pending to the extent that they were provided solely because of the requirements of this section. Recovery of the cost of medicaid services is limited to the first sixty days of services after the department or the office of administrative hearings (OAH) receives an administrative hearing request. See RCW 74.09.741.

(8) Administrative hearings include adjudicative proceedings and any other similar term referenced under chapter 34.05 RCW, the Administrative Procedure Act, Title 388 WAC, chapter 10-08 WAC, or other law. Chapter 34.05 RCW and chapter 388-02 WAC govern cases where an individual has an issue involving a service that is not funded by medicaid. Chapter 34.05 RCW and chapter 182-526 WAC govern cases where an individual has an issue involving a service that is funded by medicaid.

Notes

Wash. Admin. Code § 388-877-0675

Adopted by WSR 16-13-087, Filed 6/15/2016, effective 7/16/2016 Amended by WSR 17-20-006, Filed 9/21/2017, effective 10/22/2017