(1) If a contractor wishes to contest the way in which the department applied a statute or department rule to the contractor's circumstances, the contractor shall pursue the administrative review process prescribed in WAC
388-96-904.
(a) Adverse actions taken under the authority of this chapter or chapter
74.46 RCW subject to administrative review under WAC
388-96-904 include but are not limited to:
(i) Determining a nursing facility payment rate;
(ii) Calculating a nursing facility settlement;
(iii) Imposing a civil fine on the nursing facility;
(iv) Suspending payment to a nursing facility; or
(v) Refusing to contract with a nursing facility.
(b) Adverse actions taken under the authority of this chapter or chapter
74.46 RCW not subject to administrative review under WAC
388-96-904 include but are not limited to:
(i) Actions taken under the authority of RCW
74.46.421 and sections of this chapter implementing RCW
74.46.421;
(ii) Case mix accuracy review of minimum data set (MDS) nursing facility resident assessments, which shall be limited to separate administrative review under the provisions of WAC
388-96-905;
(iii) Quarterly rate updates to reflect changes in a facility's resident case mix including contractor errors made in the MDSs used to update the facility's resident case mix;
(iv) Exceptional direct care program codified at WAC
388-96-781; and
(v) Actions taken under WAC
388-96-218 (2)(c).
(2) The administrative review process prescribed in WAC
388-96-904 shall not be used to contest or review unrelated or ancillary department actions, whether review is sought to obtain a ruling on the merits of a claim or to make a record for subsequent judicial review or other purpose. If an issue is raised that is not subject to review under WAC
388-96-904, the presiding officer shall dismiss such issue with prejudice to further review under the provisions of WAC
388-96-904, but without prejudice to other administrative or judicial review as may be provided by law. Unrelated or ancillary actions not eligible for administrative review under WAC
388-96-904 include but are not limited to:
(a) Challenges to the adequacy or validity of the public process followed by department in proposing or making a change to the nursing facility medicaid payment rate methodology, as required by 42 U.S.C. 1396a (a)(13)(A) and WAC
388-96-718;
(b) Challenges to the nursing facility medicaid payment system that are based in whole or in part on federal laws, regulations, or policies;
(c) Challenges to a contractor's rate that are based in whole or in part on federal laws, regulations, or policies;
(d) Challenges to the legal validity of a statute or regulation; and
(e) Actions of the department affecting a medicaid beneficiary or provider that were not commenced by the office of rates management, aging and disability services administration, for example, entitlement to or payment for durable medical equipment or other services.
(3) If a contractor wishes to challenge the legal validity of a statute or regulation relating to the nursing facility medicaid payment system, or wishes to bring a challenge based in whole or in part on federal law, it must bring such action de novo in a court of proper jurisdiction as may be provided by law.
[Statutory Authority: RCW 74.46.431 (11) and (12), 74.46.800, chapter 74.46 RCW, 2004 c 276 § 913, 2001 1st sp.s. c 8. 04-21-027, § 388-96-901, filed 10/13/04, effective 11/13/04. Statutory Authority: RCW 74.46.800. 01-12-037, § 388-96-901, filed 5/29/01, effective 6/29/01. Statutory Authority: RCW 74.46.800, 74.46.508. 00-12-098, § 388-96-901, filed 6/7/00, effective 7/8/00. Statutory Authority: RCW 74.46.780 as amended by 1998 c 322 § 41. 98-20-023, § 388-96-901, filed 9/25/98, effective 10/1/98. Statutory Authority: RCW 74.46.800 and 1995 1st sp.s. c 18. 95-19-037 (Order 3896), § 388-96-901, filed 9/12/95, effective 10/13/95. Statutory Authority: RCW 74.46.800 and 74.09.120. 91-12-026 (Order 3185), § 388-96-901, filed 5/31/91, effective 7/1/91. Statutory Authority: RCW 74.09.120. 82-21-025 (Order 1892), § 388-96-901, filed 10/13/82; Order 1262, § 388-96-901, filed 12/30/77.]