Wash. Admin. Code § 388-877-0670

Current through Register Vol. 24-24, December 15, 2024

Section 388-877-0670 - Filing an appeal

(1) An individual may file an appeal to ask the behavioral health organization (BHO) to review an adverse benefit determination that the BHO has communicated on a written notice of adverse benefit determination as defined in WAC 388-877-0655. An individual's representative may appeal an adverse benefit determination with the individual's written consent. If a written notice of adverse benefit determination was not received, an appeal may still be filed.

(2) The individual requesting review of an adverse benefit determination must exhaust the appeals process before requesting an administrative hearing.

(3) Appeals may be:

(a) Standard as described in subsection (6) and (7) of this section; or

(b) Expedited if the criteria in subsection (8) of this section are met.

(4) The appeal process must:

(a) Provide an individual a reasonable opportunity to present evidence and testimony and make legal and factual arguments in person as well as in writing. The BHO must inform the individual of the limited time available.

(b) Provide the individual, free of charge and sufficiently in advance, the individual's clinical record, including new or additional evidence, medical records, and any other documents and records considered during the appeal process.

(c) Include the following, as applicable, as parties to the appeal:

(i) The individual, the individual's representative, or both; or

(ii) The legal representative of a deceased individual's estate.

(5) The BHO must ensure that the persons who make decisions on an appeal:

(a) Neither were involved in any previous level of review or decision making nor are subordinates of any person who reviewed or decided on a previous level of appeal;

(b) Are mental health or chemical dependency professionals who have appropriate clinical expertise in the type of behavioral health service if deciding an appeal of an adverse benefit determination concerning medical necessity or an appeal that involves any clinical issues; and

(c) Consider all comments, documents, records, and other information submitted by the individual regardless of whether the information was considered in the initial review.

(6)Standard appeals for adverse benefit determination-continued services not requested. An individual who disagrees with a decision communicated on a notice of adverse benefit determination may file an appeal orally or in writing. An oral filing of a standard appeal must be followed with a written and signed appeal. The BHO must use the date of an oral appeal as the official filing date to establish the earliest possible filing date. All of the following apply:

(a) The individual must file the appeal within sixty calendar days from the date on the notice of adverse benefit determination.

(b) The BHO must confirm receipt of the appeal in writing within five business days.

(c) The BHO must send the individual a written notice of the resolution as expeditiously as the individual's health condition requires, and no longer than thirty calendar days from the day the BHO received the appeal. This time frame may be extended up to fourteen additional calendar days if the individual requests an extension or the BHO is able to demonstrate to the department upon the department's request that it needs additional information and that the added time is in the individual's interest. The BHO must:

(i) Make reasonable efforts to give the individual prompt oral notice of the delay; and

(ii) Within two calendar days, give the individual written notice of the reason for the decision to extend the time frame and inform the individual of the right to file a grievance if the individual disagrees with that decision.

(d) The written notice of the resolution must include all the information listed in subsection (9) of this section.

(7)Standard appeals for termination, suspension, or reduction of previously authorized services-continued services requested. An individual who receives a notice of adverse benefit determination from the BHO that terminates, suspends, or reduces previously authorized services may file an appeal orally or in writing and request continuation of those services pending the BHO's decision on the appeal. An oral filing of a standard appeal and request for continuation of services must be followed with a written and signed appeal and include a written request for continuation of services pending the BHO's decision on the appeal. The BHO must use the date of an oral appeal as the official filing date to establish the earliest possible filing date. All of the following apply:

(a) The individual must:

(i) File the appeal with the BHO on or before the later of the following:

(A) Within ten calendar days of the date on the notice of adverse benefit determination; or

(B) The intended effective date of the BHO's proposed adverse benefit determination; and

(ii) Request continuation of services.

(b) The BHO must:

(i) Confirm receipt of the appeal and the request for continued services with the individual orally or in writing within five business days;

(ii) Send a notice in writing that follows up on any oral confirmation made; and

(iii) Include in the notice that if the appeal decision is not in favor of the individual, the BHO may recover the cost of the behavioral health services provided pending the BHO decision.

(c) The BHO's written notice of the resolution must contain all of the information listed in subsection (9) of this section.

(8)Expedited appeal process. If an individual or the individual's behavioral health provider believes that the time taken for a standard resolution of an appeal could seriously jeopardize the individual's life, physical or mental health, or ability to attain, maintain, or regain maximum function, an expedited appeal and resolution of the appeal may be requested. If the BHO denies the request for the expedited appeal and resolution of an appeal, it must transfer the appeal to the time frame for standard resolutions under subsection (6) or (7) of this section, and make reasonable efforts to give the individual prompt oral notice of the denial and follow up within two calendar days with a written notice.

(a) Both of the following apply to expedited appeal requests:

(i) The adverse benefit determination must be for denial of a requested service, termination, suspension, or reduction of previously authorized behavioral health services;

(ii) The expedited appeal must be filed with the BHO, either orally or in writing and within:

(A) Ten calendar days of the BHO's mailing the written notice of adverse benefit determination or the intended effective date of the BHO's proposed adverse benefit determination, if the individual is requesting continued benefits; or

(B) Sixty calendar days from the date on the BHO's written notice of adverse benefit determination if the individual is not requesting continued benefits.

(b) The BHO must:

(i) Confirm receipt of the request for an expedited appeal in person or by telephone.

(ii) Send the individual a written notice of the resolution as expeditiously as the individual's health condition requires, and no longer than seventy-two hours after receiving the request for an expedited appeal.

(c) The BHO may extend the time frames up to fourteen additional calendar days if the individual requests an extension or the BHO is able to demonstrate to the department upon the department's request that it needs additional information and that the added time is in the individual's interest. In this case the BHO must:

(i) Make reasonable efforts to give the individual prompt oral notice of the delay;

(ii) Within two calendar days give the individual written notice of the reason for the decision to extend the time frame and inform the individual of the right to file a grievance if the individual disagrees with that decision; and

(iii) Resolve the appeal as expeditiously as the individual's health condition requires and no later than the date the extension expires.

(d) The BHO must ensure that punitive action is not taken against a behavioral health provider who requests an expedited resolution or who supports an individual's appeal.

(9) The BHO's written notice of the resolution containing the decision on a standard appeal or expedited appeal must:

(a) Clearly state the BHO's decision on the appeal, the reason for the decision, and the date the decision was made;

(b) Inform the individual of the right to an administrative hearing if the individual disagrees with the decision, how to request a hearing, and the following time frames for requesting a hearing:

(i) Within ten calendar days from the date on the notice of the resolution if the individual is asking that services be continued pending the outcome of the hearing.

(ii) Within one hundred twenty calendar days from the date on the notice of the resolution if the individual is not asking for continued services.

(c) Be in an easily understood format following 42 C.F.R. Sec. 438.10 (2017), which includes requirements that each notice:

(i) Be written in the individual's non-English language, if applicable;

(ii) Contains the BHO's toll-free and TTY/TDY telephone number; and

(iii) Explains the availability of free written translation, oral interpretation to include any non-English language, auxiliary aids such as American sign language and TTY/TDY telephone services, and alternative formats to include large print and Braille.

(10) When the BHO does not act within the appeal process time frames explained in this section, the individual is considered to have exhausted the appeal process and has a right to request an administrative hearing.

(11)Duration of continued services during the appeal process. When an individual has requested continued behavioral health services pending the outcome of the appeal process and the criteria in this section have been met, the BHO must ensure the services are continued until one of the following occurs:

(a) The individual withdraws the appeal; or

(b) The BHO provides a written notice of the resolution that contains a decision that is not in favor of the individual and the individual does not request an administrative hearing within ten calendar days from the date the BHO mails the notice; see WAC 388-877-0675, administrative hearings, for rules on duration of continued services during the administrative hearing process.

(12)Reversal of an adverse benefit determination. If the final written notice of the resolution of the appeal or administrative hearing reverses the adverse benefit determination, the BHO must authorize or provide the behavioral health service(s) no later than seventy-two hours from the date it receives notice of the adverse benefit determination being overturned.

(13)Recovery of the cost of behavioral health services in adverse decisions of appeals. If the final written notice of the resolution of the appeal is not in favor of the individual, the BHO may recover the cost of the behavioral health services furnished to the individual while the appeal was pending to the extent that they were provided solely because of the requirements of this section. Recovery of the cost of medicaid services is limited to the first sixty days of services after the department or the office of administrative hearings (OAH) receives an administrative hearing request. See RCW 74.09.741.

(14)Recordkeeping and maintenance of appeals. The BHO must ensure that full records of all appeals and materials received and compiled in the course of processing and attempting to resolve appeals are:

(a) Kept for a period of no less than ten years after the completion of the appeal process;

(b) Made available to the department upon request as part of the state quality strategy and made available upon request to the centers for medicare and medicaid services (CMS);

(c) Kept in confidential files separate from the individual's clinical record;

(d) Not disclosed without the individual's written permission, except to the department or as necessary to resolve the appeal; and

(e) Accurately maintained and contain, at a minimum, all of the following information:

(i) A general description of the reason for the appeal;

(ii) The date received;

(iii) The date of each review or, if applicable, review meeting;

(iv) Resolution at each level of the appeal, if applicable;

(v) Date of resolution at each level, if applicable; and

(vi) Name of the covered person for whom the appeal was filed.

Wash. Admin. Code § 388-877-0670

Adopted by WSR 16-13-087, Filed 6/15/2016, effective 7/16/2016

Amended by WSR 17-20-006, Filed 9/21/2017, effective 10/22/2017