182-538-100  <<  182-538-110 >>   182-538-111

The grievance system for managed care organizations (MCO).

(1) This section contains information about the grievance system for managed care organization (MCO) enrollees. See WAC 182-538-111 for information about PCCM enrollees.
(a) Each MCO must have a grievance system in place for enrollees. The system must comply with the requirements of 42 C.F.R. 438 Subpart F, medicaid agency rules in Title 182 WAC, and the rules of the state office of insurance commissioner (OIC) in chapter 284-43 WAC.
(b) The agency's hearing rules in chapter 182-526 WAC apply to administrative hearings requested by enrollees to review resolution of an enrollee appeal of an MCO action.
(c) If a conflict exists between the requirements of this chapter and other rules, the requirements of this chapter take precedence.
(2) MCO grievance system.
(a) The MCO grievance system must include:
(i) A process for addressing complaints about any matter that is not an action, which is called a grievance;
(ii) An appeals process to address requests for review of an MCO action;
(iii) Access to an independent review (IR) by an independent review organization (IRO) in accordance with RCW 48.43.535 and WAC 182-526-0200; and
(iv) 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 system to all providers and subcontractors.
(c) An MCO must have agency approval for written materials sent to enrollees regarding the grievance system.
(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 system.
(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. MCOs may not require enrollees to provide written follow up for a grievance or an appeal the MCO received orally.
(g) 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.
(h) The MCO must ensure that the individuals who make decisions on grievances and appeals are individuals:
(i) Who were not involved in any previous level of review or decision making; and
(ii) Are health care professionals who have appropriate clinical expertise in treating the enrollee's condition or disease if deciding any of the following:
(A) An appeal of an action 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.
(3) The MCO grievance process.
(a) Only an enrollee or enrollee's authorized representative may file a grievance with an MCO. A provider may not file a grievance on behalf of an enrollee without the enrollee's written consent.
(b) An MCO must acknowledge receipt of each grievance filed orally or in writing within two business days.
(c) The MCO must complete the disposition 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 disposition of grievances within five business days of determination.
(i) Notices of disposition of grievances not involving clinical issues can be oral or in writing.
(ii) Notices of disposition of grievances for clinical issues must be in writing.
(e) Enrollees do not have a right to an administrative hearing in regards to the disposition of a grievance.
(4) The MCO's notice of action.
(a) Language and format requirements. The notice of action must be in writing in enrollee's primary language, and in an easily understood format, in accordance with 42 C.F.R. Sec. 438.404.
(b) Content of notice of action. The notice of MCO action must explain:
(i) The MCO's action or action the MCO intends to take;
(ii) The reasons for the action, including citation to rules or regulations and the MCO criteria that were the basis of the decision;
(iii) The enrollee's right to file an appeal;
(iv) The procedures for exercising the enrollee's rights;
(v) The circumstances under which expedited resolution is available and how to request it;
(vi) 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 of action. The MCO must mail the notice of action within the following time frames:
(i) For termination, suspension, or reduction of previously authorized services, at least ten calendar days prior to such action 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 action affecting the claim. This applies only when the client can be held liable for the costs associated with the action.
(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 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 three business days after receipt of the request for service.
(B) The MCO may extend the three business days 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 a need for additional information and it is in the enrollee's interest.
(5) The MCO appeals process.
(a) An enrollee, the enrollee's authorized representative, or the provider acting with the enrollee's written consent, may appeal an MCO action.
(b) An MCO must treat oral inquiries about appealing an action 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) The MCO must acknowledge receipt of each appeal to both the enrollee and the requesting provider within three calendar days. The appeal acknowledgment letter sent by the MCO serves as written confirmation of an appeal filed orally by an enrollee.
(d) For appeals involving standard service authorization decisions, an enrollee must file an appeal within ninety calendar days of the date on the MCO's notice of action. This time frame also applies to a request for an expedited appeal.
(e) For appeals of actions 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 action.
(f) When the MCO does not reach service authorization decisions within required time frames, it is considered a denial. In this case the MCO sends a formal notice of action, including the enrollee's right to an appeal.
(g) The MCO appeals process must:
(i) Provide the enrollee a reasonable opportunity to present evidence and allegations of fact or law, both in person and 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 appeals process to examine the enrollee's case file, including medical records and any other documents and records considered during the appeals process; 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) Time frames for resolution of appeals. 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 forty-five 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, or appeals of mental health drug authorization decisions, including notice to the affected parties, no longer than three calendar days after the MCO receives the appeal.
(i) Notice of resolution of appeal. The notice of the resolution of the appeal must:
(i) Be in writing and be sent to the enrollee and the requesting provider. For notice of an expedited resolution, the MCO must also make reasonable efforts to provide oral notice.
(ii) Include the results of the resolution process and the date it was completed.
(j) Administrative hearing rights. For appeals not resolved wholly in favor of the enrollee, the notice of resolution of the appeal must:
(i) Include information on the enrollee's right to request an agency administrative hearing and how to do so as provided in the agency hearing rules in WAC 182-526-0200;
(ii) Include information on the enrollee's right to receive services while the hearing is pending and how to make the request as described in the agency hearing rules in WAC 182-526-0200; and
(iii) Inform the enrollee that the enrollee may be held liable for the cost of services received for the first sixty days after an administrative hearing request is received by the agency or the office of administrative hearings (OAH), if the hearing decision upholds the MCO's action.
(6) MCO expedited appeal process.
(a) Each MCO must establish and maintain an expedited appeal review process for appeals when the MCO determines or provider indicates that taking the time for a standard resolution could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function.
(b) The enrollee may file an expedited appeal either orally 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 three 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 days if:
(i) The enrollee requests the extension; or
(ii) The MCO determines there is a need for additional information and the delay is in the enrollee's interest.
(e) The MCO must 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 health condition requires, but not later than three business days after receiving the appeal.
(g) 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.
(h) The MCO must ensure that punitive action is not taken against a provider who requests an expedited resolution or supports an enrollee's appeal.
(7) Administrative hearing.
(a) Only an enrollee or enrollee's authorized representative may request an administrative hearing. A provider may not request a hearing on behalf of an enrollee.
(b) If an enrollee does not agree with the MCO's resolution of an appeal, the enrollee may file a request for an agency administrative hearing based on the rules in this section and the agency hearing rules in WAC 182-526-0200.
(c) The MCO is an independent party and responsible for its own representation in any administrative hearing, independent review, appeal to the board of appeals, and any subsequent judicial proceedings.
(d) An enrollee must exhaust the appeals process within the MCO's grievance system before requesting an administrative hearing with the agency.
(8) Continuation of previously authorized services during the appeal process.
(a) The MCO must continue the enrollee's services if all of the following apply:
(i) The enrollee or the provider files the appeal on or before the later of the following:
(A) Within ten calendar days of the MCO mailing the notice of action involving services previously authorized; or
(B) The intended effective date of the MCO's proposed action.
(ii) The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;
(iii) The services were ordered by an authorized provider;
(iv) The original period covered by the original authorization has not expired; and
(v) The enrollee requests an extension of services.
(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 appeal;
(ii) Ten calendar days pass after the MCO mails notice of the resolution of the appeal against the enrollee and the enrollee has not requested an agency administrative hearing with continuation of services during the ten day time frame;
(iii) OAH issues a hearing decision adverse to the enrollee;
(iv) The time period or service limits of a previously authorized service has been met.
(c) If the final resolution of the appeal upholds the MCO's action, 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 request for hearing was received by the agency or OAH, to the extent that services were provided solely because of the requirement for continuation of services.
(9) Effect of reversed resolutions of appeals.
(a) If the MCO, or a final order 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.
(b) 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 and 41.05.160. WSR 15-24-098, § 182-538-110, filed 12/1/15, effective 1/1/16. Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. WSR 13-02-010, § 182-538-110, filed 12/19/12, effective 2/1/13. WSR 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. WSR 08-15-110, § 388-538-110, filed 7/18/08, effective 8/18/08; WSR 06-03-081, § 388-538-110, filed 1/12/06, effective 2/12/06; WSR 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. WSR 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. WSR 00-04-080, § 388-538-110, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090. WSR 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. WSR 95-18-046 (Order 3886), § 388-538-110, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. WSR 94-04-038 (Order 3701), § 388-538-110, filed 1/26/94, effective 2/26/94; WSR 93-17-039 (Order 3621), § 388-538-110, filed 8/11/93, effective 9/11/93.]