Section 388-877-0665 - Notice of adverse benefit determination(1) A behavioral health organization's (BHO's) notice of adverse benefit determination provided to an individual must be in writing and in an easily understood format following 42 C.F.R. Sec. 438.10 (2017), which includes requirements that each notice: (a) Be written in the individual's non-English language, if applicable;(b) Contains the BHO's toll-free and TTY/TDY telephone number; and(c) Explains the availability of free written translation, oral interpretation to include any non-English language, auxiliary aids such as American sign language, TTY/TDY telephone services, and alternative formats to include large print and Braille.(2) The notice of adverse benefit determination must, at a minimum, explain the following: (a) The adverse benefit determination the BHO has made or intends to make;(b) The reasons for the adverse benefit determination, including citation of the rule(s) and criteria used for the basis of the decision;(c) The right of the individual to be provided reasonable access to and copies of all documents, records, and other information relevant to the individual's adverse benefit determination upon request and free of charge;(d) The individual's right to file an appeal of the adverse benefit determination with the BHO, including information on exhausting the BHO's one level of appeal and the individual's right to request an administrative hearing;(e) The circumstances under which an expedited appeal process is available and how to request it; and(f) The individual's right to receive behavioral health services while an appeal is pending, how to make the request, and that the individual may be held liable for the cost of services received while the appeal is pending if the appeal decision upholds the decision in the notice of adverse benefit determination.(3) When the BHO or its contracted behavioral health agency does not reach service authorization decisions within the required time frame, or fails to provide services in a timely manner, it is considered an adverse benefit determination. In these cases, the BHO sends a formal notice of adverse benefit determination that includes the individual's right to request an administrative hearing. When the BHO does not act within the grievance and appeal system time frames as identified within this chapter, it is considered exhaustion of the appeals process and the individual has a right to request an administrative hearing.Wash. Admin. Code § 388-877-0665
Adopted by WSR 16-13-087, Filed 6/15/2016, effective 7/16/2016Amended by WSR 17-20-006, Filed 9/21/2017, effective 10/22/2017Reviser's note:RCW 34.05.395 requires the use of underlining and deletion marks to indicate amendments to existing rules. The rule published above varies from its predecessor in certain respects not indicated by the use of these markings.