Date of Adoption: October 20, 2000.

Purpose: To comply with the Governor's Executive Order 97-02 on regulatory reform, and update rule to reflect current department policy.

Citation of Existing Rules Affected by this Order: Amending WAC 388-502-0230.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.520, 34.05.020, 34.05.220.

Adopted under notice filed as WSR 00-17-163 on August 22, 2000.

Changes Other than Editing from Proposed to Adopted Version: WAC 388-502-0230 (3)(e) "Impose provisional stipulations for the provider to continue on participation in medical assistance programs." Eliminated subsection (5)(d) "The hearing referenced in this subsection i sht final level of administrative review."

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0. Effective Date of Rule: Thirty-one days after filing.

October 20, 2000

Edith M. Rice, Chief

Office of Legal Affairs

((A certified provider of medical care services who is assessed a civil penalty under RCW 74.09.210 or otherwise served with notice that repayment of excess benefits is due under RCW 74.09.210, shall have the right to a fair hearing as provided by chapter 388-08 WAC)) (1) As authorized by chapter 74.09 RCW, the medical assistance administration (MAA) monitors and reviews all providers who furnish medical, dental, or other services to eligible medical assistance clients. MAA determines whether the providers are complying with the rules and regulations of the program(s) and providing appropriate quality of care, and recovers any identified overpayments. Examples of provider reviews are:

     (a) A review of all billing/medical/dental/service records for medical assistance clients;

     (b) A statistical sampling of billing/medical/dental/service records for medical assistance clients, extrapolated per WAC 388-502-0240 (9), (10), and (11); and

     (c) A review focused on selected billing/medical/dental/service records for medical assistance clients.

     (2) The Washington State Health Professions Quality Assurance Commissions serve in an advisory capacity to MAA in conducting provider reviews and monitoring.

     (3) MAA may determine that a provider's billing does not comply with program regulations or the provider is not meeting quality of care practices. MAA may do, but is not limited to, any of the following:

     (a) Conduct pre-pay reviews of all claims the provider submits to MAA;

     (b) Refer the provider to MAA's auditors (see WAC 388-502-0240);

     (c) Refer the provider to Medicaid's Fraud Control Unit;

     (d) Refer the provider to the appropriate state health professions quality assurance commission;

     (e) Impose provisional stipulations for the provider to continue participation in medical assistance programs;

     (f) Terminate the provider's participation in medical assistance programs;

     (g) Assess a civil penalty against the provider, per RCW 74.09.210; and

     (h) Recover any monies that the provider received as a result of inappropriate payments.

     (4) When any part of the time period that is reviewed or monitored falls on or before June 30, 1998, the following process applies. A provider who disagrees with a department action regarding overpayment recovery may request an administrative review hearing to dispute the action(s).

     (a) The request for an administrative review hearing must be in writing and:

     (i) Be sent within twenty-eight days of the date of the notice of action(s);

     (ii) State the reason(s) why the provider thinks the action(s) are incorrect;

     (iii) Be sent by certified mail (return receipt) or other means that provides proof of delivery to:

     The Medical Assistance Administration

     Attn: Deputy Assistant Secretary

     P.O. Box 45500

     Olympia WA 98504-5500

     (b) The administrative review hearing consists of a review by MAA's deputy assistant secretary of all documents submitted by the provider and MAA. At the deputy assistant secretary's discretion, the administrative review hearing may be conducted in person, as a telephone conference, in written submissions, or a combination thereof.

     (c) When a final decision is issued, the office of financial recovery collects any amount the provider is ordered to repay.

     (d) The administrative review hearing referenced in this subsection is the final level of administrative review.

     (5) When the entire time period that is reviewed or monitored falls on or after July 1, 1998, the following process applies. A provider who disagrees with a department action regarding overpayment recovery may request a hearing to dispute the action(s).

     (a) The request for hearing must be in writing and;

     (i) Be sent within twenty-eight days of the date of the notice of action(s), by certified mail (return receipt) or other means that provides proof of delivery to:

     The Office of Financial Recovery

     P.O. Box 9501

     Olympia, WA 98507-5501; and

     (ii) State the reason(s) why the provider thinks the action(s) are incorrect.

     (b) The office of administrative hearings schedules and conducts the hearing under the Administrative Procedure Act, chapter 34.05 RCW. MAA offers a pre-hearing/alternative dispute conference prior to the hearing.

     (c) The office of financial recovery collects any amount the provider is ordered to repay.

     (6) A provider who disagrees with a department action regarding termination may appeal the action per WAC 388-502-0260. The provider may request a dispute conference; the request must be:

     (a) In writing;

     (b) Sent within thirty days of the date the provider received the termination notice;

     (c) Include a statement of the action(s) appealed and supporting justification; and

     (d) Sent to:

     DSHS Central Contract Services

     P.O. Box 45811

     Olympia, WA 98504-5811

     (7) See WAC 388-502-0220 for rate reimbursement appeals. See WAC 388-502-0240 for appeals of audit findings. See WAC 388-502-0260 for appeals related to contracts other than MAA's core provider agreements.

[Statutory Authority: RCW 74.08.090.      94-10-065 (Order 3732), § 388-502-0230, filed 5/3/94, effective 6/3/94.      Formerly WAC 388-81-042.]

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