(1) This section contains information about the grievance system for primary care case management (PCCM) enrollees, which includes grievances and appeals. See WAC
182-538-110 for information about the grievance system for managed care organization (MCO) enrollees.
(2) A PCCM enrollee may voice a grievance or file an appeal, either orally or in writing. PCCM enrollees use the agency's grievance and appeal processes.
(3) The grievance process for PCCM enrollees;
(a) A PCCM enrollee may file a grievance with the agency. A provider may not file a grievance on behalf of a PCCM enrollee.
(b) The agency provides PCCM enrollees with information equivalent to that described in WAC
182-538-110 (7)(c).
(c) When a PCCM enrollee files a grievance with the agency, the enrollee is entitled to:
(i) Any reasonable assistance in taking procedural steps for grievances (e.g., interpreter services and toll-free numbers);
(ii) Acknowledgment of the agency's receipt of the grievance;
(iii) A review of the grievance. The review must be conducted by an agency representative who was not involved in the grievance issue; and
(iv) Disposition of the grievance and notice to the affected parties within ninety days of the agency receiving the grievance.
(4) The appeal process for PCCM enrollees:
(a) A PCCM enrollee may file an appeal of an agency action with the agency. A provider may not file an appeal on behalf of a PCCM enrollee.
(b) The agency provides PCCM enrollees with information equivalent to that described in WAC
182-538-110 (8)(c).
(c) The appeal process for PCCM enrollees follows that described in chapter
182-526 WAC. Where a conflict exists, the requirements in this chapter take precedence.
[Statutory Authority: RCW 41.05.021, 42 C.F.R. 438. 13-02-010, § 182-538-111, filed 12/19/12, effective 2/1/13. 11-14-075, recodified as § 182-538-111, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.522. 08-15-110, § 388-538-111, filed 7/18/08, effective 8/18/08; 06-03-081, § 388-538-111, filed 1/12/06, effective 2/12/06; 03-18-110, § 388-538-111, filed 9/2/03, effective 10/3/03.]