Non-Grant Medical Assistance (NGMA) hearings

Revised date

Clarifying information

The Office of Administrative Hearings schedules the following hearing types as HCA Hearings and sends a notice of the hearing to the DSHS Administrative Hearing Coordinator (AHC):

  • Non-Grant Medical Assistance decisions made by Division of Disability Determination Services (DDDS).
  • Medical Assistance decisions made by the Health Care Authority regarding:
    • Medical equipment and services, or
    • Managed care eligibility or services, or
    • Restricted use of medical care, or
    • Coordination of Benefits (TPL) issues.

Representation may be from the department, agency, or office that made the decision (e.g. issue related to denial of a medical service or choice of a managed care plan).

In most situations, the AHC acts as the agency representative and the other office or agency provides witnesses to testify regarding the Department or agency decision that is being contested.

AHC responsibilities

There are several offices within the (HCA) that make decisions which are subject to administrative hearings. It is important to contact the appropriate office as soon as a notice of hearing is received to coordinate representation.

  1. Medical assistance hearings:
    1. For hearings involving medical services, equipment, transportation, managed care enrollment, and Patient Review and Coordination (PRC) program contact the HCA's Office of Hearings and Appeals at: MS 445531, 360-725-1254 or 800-351-6827.
      1. The HCA staff may act as the agency's representative for these cases, coordinate testimony of medical consultants, help obtain additional medical information, and arrange medical examinations, if necessary.
      2. The HCA Appeals Administrator will coordinate review and implementation of hearing decisions as required by HCA.
      3. The DSHS AHC acts as liaison between HCA staff and the Appellant and their representative if required. For example, if the Appellant requests an in-person hearing and it is scheduled at the local CSO, the DSHS AHC may assist the ALJ and the Appellant during the hearing because HCA staff participates in the hearing telephonically from Olympia, WA.
  2. For insurance issues, contact HCA's Revenue, Recovery and Premium Payment Section or HCA's Coordination of Benefits Section, as appropriate:
    1. COB Health Units: 800-562-3022 ext # 16134
    2. COB Casualty Unit: 800-562-3022 ext # 15462
    3. RRPS Premium Payment: 800-562-3022 ext # 15473
  3. For eligibility and policy issues, when clarification is required, contact the eligibility representative in the Office of Medicaid Eligibility & Policy (OMEP), MS 45534.
  4. For hearings involving CHIP (N13), After Pregnancy Coverage (N04/N24/N07/N27), BCCTP (S30) or other cases assigned to CSO 76 contact Ariane Takano 360-725-1795 MS 45531 or contact 800-351-6827.
  5. Non-grant medical assistance (NGMA) hearings: The AHC acts as the agency representative, and a Division of Disability Determination Services (DDDS) employee provides testimony to support the decision. Individuals have up to 90 days to request a hearing on a NGMA decision. As soon as the hearing request is received:
    1. Initiate reconsideration of the original decision by completing in hard copy a DSHS 14-144, Transmittal Summary, and check the box for Administrative Hearing Review. The reconsideration is a required step in the DDDS process prior to hearing. Request continuances as appropriate to allow sufficient time for the reconsideration.
    2. Forward the DSHS 14-144 and the DDDS original decision packet in hard copy to the appropriate DDDS office. Attach any new medical documentation and release of information authorizations, if appropriate. (Do not use the automated Barcode referral process for administrative hearing reviews.)
    3. Notify DDDS of the scheduled date and time of the hearing.
    4. Coordinate requested continuances from either the appellant or DDDS with the local OAH office. Continuances are often necessary in these cases to obtain additional medical information. It is important that the AHC keep all parties informed of the status of the case prior to the hearing.
    5. Notify the appellant if the original DDDS decision is reversed in the DDDS review process.
    6. If the original denial is affirmed in the DDDS review process, consult with the DDDS hearing supervisor who will assign someone to testify in support of the denial.

Note: A hearing request is not always needed for the Dept. to review a NGMA decision. Individuals may ask for a review within 30 days of the initial denial if medical evidence exists that was not used to make the original decision. Please follow the above steps and note on the referral that it is a reconsideration of denial.

DDDS hearings contact :
Michael Magill
Hearings manager
360-664-7394
MS 45550

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