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WAC 182-502-0220

Administrative appeal contractor or provider rate reimbursement.

(1) Any enrolled contractor or provider of medical services has a right to an administrative appeal when the contractor or provider disagrees with the medicaid agency reimbursement rate. The exception to this is nursing facilities governed by WAC 388-96-904.
(2) The first level of appeal. A contractor or provider who wants to contest a reimbursement rate must file a written appeal with the agency.
(a) The appeal must include the following:
(i) A statement of the specific issue being appealed;
(ii) Supporting documentation; and
(iii) A request for the agency to recalculate the rate.
(b) When a contractor or provider appeals a portion of a rate, the agency may review all components of the reimbursement rate.
(c) To complete a review of the appeal, the agency may do one or both of the following:
(i) Request additional information; and
(ii) Conduct an audit of the documentation provided.
(d) The agency issues a decision or requests additional information within sixty calendar days of receiving the rate appeal request.
(i) When the agency requests additional information, the contractor or provider has forty-five calendar days from the date of the agency's request to submit the additional information.
(ii) The agency issues a decision within thirty calendar days of receipt of the completed information.
(e) The agency may adjust rates retroactively to the effective date of a new rate or a rate change. In order for a rate increase to be retroactive, the contractor or provider must file the appeal within sixty calendar days of the date of the rate notification letter from the agency. The agency does not consider any appeal filed after the sixty-day period to be eligible for retroactive adjustment.
(f) The agency may grant a time extension for the appeal period if the contractor or provider makes such a request within the sixty-day period described in (e) of this subsection.
(g) Any rate increase resulting from an appeal filed within the sixty-day period described in subsection (2)(e) of this section is effective retroactively to the rate effective date in the notification letter.
(h) Any rate increase resulting from an appeal filed after the sixty-day period described in subsection (2)(e) of this section is effective on the date the rate appeal is received by the agency.
(i) Any rate decrease resulting from an appeal is effective on the date specified in the appeal decision letter.
(j) Any rate change that the agency grants that is the result of fraudulent practices on the part of the contractor or provider as described under RCW 74.09.210 is exempt from the appeal provisions in this chapter.
(3) The second level of appeal. When the contractor or provider disagrees with a rate review decision, it may file a request for a dispute conference with the agency. For this section "dispute conference" means an informal administrative hearing to resolve contractor or provider disagreements with an agency action as described under subsection (1) of this section and not agreed upon at the first level of appeal. The dispute conference is not governed by the Administrative Procedure Act, chapter 34.05 RCW.
(a) If a contractor or provider files a request for a dispute conference, it must submit the request to the agency within thirty calendar days after the contractor or provider receives the rate review decision. The agency does not consider dispute conference requests submitted after the thirty-day period for the first level decision.
(b) The agency conducts the dispute conference within ninety calendar days of receiving the request.
(c) An agency-appointed conference chairperson issues the final decision within thirty calendar days of the conference. Extensions of time for extenuating circumstances may be granted if all parties agree.
(d) Any rate increase or decrease resulting from a dispute conference decision is effective on the date specified in the dispute conference decision.
(e) The dispute conference is the final level of administrative appeal within the agency and precedes judicial action.
(4) The agency considers that a contractor or provider who fails to attempt to resolve disputed rates as provided in this section has abandoned the dispute.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0220, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0220, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-502-0220, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090 and 74.09.730. WSR 99-16-070, § 388-502-0220, filed 8/2/99, effective 9/2/99. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-502-0220, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-043.]
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