Clarifying information
The clarifying information on this page applies to eligibility decisions for Apple Health programs.
Acronyms and definitions
An administrative law judge (ALJ) is an impartial decision-maker who is an attorney and presides at an administrative hearing. ALJs are employed by the office of administrative hearings (OAH), which is a separate state agency, as defined in RCW 34.05.010. ALJs are not Department of Social and Health Services or Health Care Authority (HCA) employees or representatives.
An appellant is a person or entity who requests a hearing about an action of HCA or its designee.
The hearing record is the official documentation of the hearing process. The record includes recordings or transcripts, admitted exhibits, decisions, briefs, notices, orders, and other filed documents.
Find out what the Office of Administrative Hearings (OAH) does in the appeals process.
Types of orders
- Prehearing meeting (WAC 182-526-0175): This is an informal meeting between HCA and the appellant and does not involve the ALJ. It can take place by phone, email, or in-person. The purpose is to:
- Clarify the issue(s).
- Exchange information.
- Resolve any issues through an agreement or withdrawal.
- Explain any rules or laws and answer questions.
- Notice of hearing (182-526-0255): This is a formal notice of the date, time, and location of the administrative hearing. This notice is sent to all parties, including the appellant and all agencies involved, such as HCA, DSHS (if the hearing is about a Classic Medicaid case), and OAH. It includes:
- A copy of the request for an administrative hearing
- Contact information for the parties
- The docket numbers,
- A summary of the appellant's legal rights
- A referral to potentially free legal resources that are available.
- Prehearing conference (WAC 182-526-0195): This is a formal notice of a meeting mailed to all parties and includes HCA, the appellant, and an ALJ. This can be used to:
- Clarify any issues
- Set deadlines,
- Agree to a continuance,
- Resolve the dispute,
- Determine eligibility for continued coverage,
- Address other issues.
If the appellant fails to show, the ALJ may issue an order of default and dismiss the hearing.
- Order of dismissal (WAC 182-526-0285): This is an order issued by an ALJ when an appellant withdraws the hearing request or does not appear for the hearing. The most common reasons for an order of dismissal are:
- Default/no show: The appellant fails to appear.
- Withdrawal: The appellant withdrew their request for hearing.
An appellant can request in writing that an Order of Dismissal be vacated (i.e., canceled) or set aside (see WAC 182-526-0290). A prehearing conference is scheduled. The ALJ issues a written order which will explain whether the appellant has established good cause (see WAC 182-526-0020) to have the hearing reinstated. If the ALJ determines good cause exists to vacate the dismissal order, the ALJ schedules a hearing.
- Order of Continuance (WAC 182-526-0280): A continuance is a rescheduling of a hearing to a later time or date. If a party would like a continuance, the party must see if the other parties agree. If so, an order of continuance is issued by OAH. If any of the other parties disagrees with the continuance, a prehearing conference is held. The ALJ either approves or denies the continuance request after the conference.
- Initial decision (WACs 182-526-0520 to 182-526-0595): The decision issued by the ALJ who presided at the hearing. The initial decision becomes the final decision if it is not appealed by either party within 21 calendar days after OAH mails the order. The ALJ who conducted the hearing is responsible for writing the initial decision and mail a copy to all parties. The order will:
- List all parties, witnesses, and exhibits (evidence).
- Determine the facts of the case.
- Explain why evidence or a witness is or is not credible.
- State the applicable laws and rules that apply to the issue.
- Discuss the reasons for the decision and how the laws apply to it.
- State the result and remedy being ordered and
- Explain the appeals process.
- Request for Reconsideration (WAC 182-526-0560 to 182-526-0635): When the ALJ issues an initial order, any party may request the ALJ to reconsider the decision. The request for reconsideration must be received by OAH on or before the 10th calendar day after the initial order was mailed. The ALJ can only consider evidence that was presented in the hearing unless the ALJ reopens the hearing record (see WAC 182-526-0500). The ALJ will issue a written order in response to the request for reconsideration.
- Judicial Review (WACs 182-526-0640 to 182-526-0650): Only the appellant has the right to request a judicial review of the final agency decision in superior court. Instructions regarding requesting judicial review are attached to the initial decision.
Worker responsibilities
When a decision is received, document in the ACES narrative the docket number, the type of decision, and the date of mailing. Include any other information necessary, including the outcome of the hearing.
- Order of Dismissal:
- Default/no show: If the hearing notice was sent to the appellant's reported address and the appellant failed to appear:
- document the ACES narrative, and
- file the decision with any related documents in the case record.
Note: If the hearing notice was sent to an address other than the appellant's reported address or there is some other reason that the notice of hearing was not properly delivered, contact the OAH and provide the correct address or other information needed to deliver the notice.
- Withdrawal: Document the ACES narrative and send the decision, with the request for withdrawal and any other related documents, to be imaged into Barcode.
- Reversed decisions: When the agency's decision is reversed, immediately:
- Review the decision to determine if a request for reconsideration is needed. If so:
- Document in ACES the reason for the request for reconsideration.
- Send the request to OAH with a copy to the appellant.
- If no request for reconsideration is needed:
- Reopen or approve coverage back to the date the action took place.
- Document the actions and decision and
- Send a letter to the household advising them of the hearing outcome and action taken to approve coverage.
- Affirmed decisions: When the agency's decision is affirmed, immediately:
- Terminate continued coverage. Adequate notice must be provided to the appellant, but advance notice is not required.
- Review the period of continued coverage, and establish overpayments as appropriate.
- Document in ACES the decision.
- Petition for review of initial decision:
- After implementing the initial decision, determine if a review is appropriate:
- Consult with a supervisor, administrator, or program manager, as appropriate.
- Consult with training or program management staff (i.e., Office of Medicaid Eligibility and Policy), if necessary.
- If the decision is made to petition for a review of the initial decision, prepare a memorandum for the Board of Appeals. Include:
- Appellant's name and docket number.
- All areas in which the agency believes the ALJ erred. See WAC 182-526-0575 for the review standard. The review judge usually only addresses areas that have been raised in the petition. Refer to findings of fact and conclusions of law by the number assigned in the decision.
- Cite WACs, findings of fact, or evidence in the record that support the agency's argument.
- New evidence which affects the decision and was not available for the initial hearing (even after reasonable diligence) can be brought up in the review.
- A request for the review judge to find in the agency's favor.
- Ensure the review is sent to the Board of Appeals and all other parties within the stated deadlines.
- Appellant petition for review:
- Do not reinstate continued coverage pending a review of the initial decision requested by the appellant.
- Review the appellant's petition to determine an appropriate response.
- If a response is required, prepare a memorandum to the Board of Appeals and include:
- The appellant's name and the docket number.
- A response which speaks only to the issues raised by the appellant.
- Argument which supports the finding in the initial decision.
- Ensure the response is sent to the Board of Appeals and all other parties within the stated deadlines.
- Receipt of review decision:
- Implement the review decision immediately.
- See WAC 182-526-0605 to determine if a request for reconsideration is appropriate.
- If a reconsideration is appropriate, prepare a memorandum to the Board of Appeals including the specific reason why the department does not agree with the review decision.