(1) General requirements. This section contains information about the third-party administrator (TPA) grievance and appeal process and the medicaid agency's administrative hearing process for clients relating to housing transition navigation services.
(a) The TPA must have a grievance and appeal process and access to an agency administrative hearing to allow clients to file grievances and seek review of a TPA adverse benefit determination as defined in WAC 182-565-0110.
(b) The agency's administrative hearing rules in chapter 182-526 WAC apply to agency administrative hearings requested by a client to review the resolution of a client's appeal of a TPA adverse benefit determination.
(c) The TPA's policies and procedures regarding the grievance process must be approved by the agency.
(d) The TPA must maintain records of grievances and appeals.
(2) TPA grievance and appeal process. The TPA grievance and appeal process must include:
(a) A grievance process for addressing complaints about any matter that is not an adverse benefit determination;
(b) A TPA appeals process to address a client's request for review of a TPA adverse benefit determination;
(c) Access to the agency's administrative hearing process for review of a TPA's resolution of an appeal; and
(d) Allowing the client and the client's authorized representative to file grievances and appeals orally or in writing. The TPA cannot require clients to provide written follow up for a grievance or an appeal that the TPA received orally.
(3) Notice requirements.
(a) The TPA must send written notice when it:
(i) Approves the client's health-related social needs services (HRSN) eligibility and authorizes the delivery of services; or
(ii) Denies the client's HRSN eligibility.
(b) The TPA must follow the notice and timeline requirements under chapter 182-518 WAC for these notices.
(4) The TPA grievance process.
(a) A client or client's authorized representative may file a grievance with the TPA. A provider may not file a grievance on behalf of a client without the client's written consent.
(b) Clients do not have a right to an agency administrative hearing regarding the resolution of a grievance.
(c) The TPA must acknowledge receipt of each grievance either orally or in writing within two business days.
(d) The TPA must notify clients of the resolution of grievances within five business days of determination.
(5) The TPA appeals process.
(a) A client, the client's authorized representative, or a provider acting on behalf of the client with the client's written consent may appeal a TPA adverse benefit determination.
(b) The TPA must treat oral inquiries about appealing an adverse benefit determination as an appeal to establish the earliest possible filing date for the appeal. The TPA must confirm the oral appeal in writing.
(c) The TPA must acknowledge in writing the receipt of each appeal to both the client and the requesting provider within five calendar days of receiving the appeal request. The appeal acknowledgment letter sent by the TPA serves as written confirmation of an appeal filed orally by a client.
(d) The client must file an appeal of a TPA action within 60 calendar days of the date on the TPA's notice of adverse benefit determination.
(e) The TPA must continue services pending the results of an appeal or subsequent agency administrative hearing.
(f) The TPA internal appeal process must:
(i) Provide the client a reasonable opportunity to present evidence and allegations of fact or law, both in person and in writing;
(ii) Provide the client and the client's representative the client's case file, other documents and records, and any new or additional evidence considered, relied upon, or generated by the TPA (or at the direction of the TPA) in connection with the action. This information must be provided free of charge in advance of the resolution time frame for appeals as specified in this section; and
(iii) Include as parties to the appeal:
(A) The client and the client's authorized representative; and
(B) The legal representative of the deceased client's estate.
(g) The TPA must ensure that the people making decisions on appeals were not involved in any previous level of review or decision making.
(h) Time frames for resolution of appeals. The TPA:
(i) Must resolve each appeal and provide notice as expeditiously as the client's health condition requires and no longer than three calendar days after the day the TPA receives the appeal.
(ii) May extend the time frame by an additional 14 calendar days if it is necessary in order to complete the appeal.
(i) Notice of resolution of appeal. The notice of the resolution of the appeal must:
(i) Be in writing and be sent to the client and the requesting provider;
(ii) Include the results of the resolution of the appeal process and the date it was completed; and
(iii) Include information on the client's right to request an agency administrative hearing and how to do so as provided in the agency hearing rules under WAC 182-526-0095, if the appeal is not resolved wholly in favor of the client.
(j) Deemed completion of the TPA appeal process. If the TPA fails to adhere to the notice and timing requirements for appeals, the client is deemed to have completed the TPA's appeals process and may request an agency administrative hearing under WAC 182-526-0095.
(6) Agency administrative hearing.
(a) Only a client or the client's authorized representative may request an agency administrative hearing. A provider may not request a hearing on behalf of a client.
(b) If the client does not agree with the TPA's resolution of an appeal at the completion of the TPA appeal process, the client may file a request for an agency administrative hearing based on the rules in this section and the agency hearing rules in chapter 182-526 WAC. The client must request an agency administrative hearing within 90 calendar days of the notice of resolution of appeal.
(c) The TPA is an independent party and responsible for its own representation in any administrative hearing, appeal to the board of appeals, and any subsequent judicial proceedings.
(7) Effect of reversed resolutions of appeals. If the TPA or a final order as defined in chapter 182-526 WAC reverses a decision to deny or limit services, the TPA must authorize or provide the disputed services promptly and as expeditiously as the client's circumstances require.
(8) Funding unavailable. When available resources are exhausted, any appeals process or agency administrative hearing process related to a request to authorize a service will be terminated, since services cannot be authorized without funding regardless of medical necessity.