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182-538-110  <<  182-538-111 >>   182-538-120

WAC 182-538-111

Agency filings affecting this section

Primary care case management (PCCM) grievances and appeals.

(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. WSR 13-02-010, § 182-538-111, filed 12/19/12, effective 2/1/13. WSR 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. WSR 08-15-110, § 388-538-111, filed 7/18/08, effective 8/18/08; WSR 06-03-081, § 388-538-111, filed 1/12/06, effective 2/12/06; WSR 03-18-110, § 388-538-111, filed 9/2/03, effective 10/3/03.]