WAC 182-526-0200 Enrollee appeals of a managed care organization action.

Effective December 22, 2017

1. The hearing process described in this chapter applies to enrollee appeals of a health care authority (HCA)-contracted managed care organization (MCO) action. Where a conflict exists, the requirements in this section prevail.
2. An MCO enrollee must exhaust all levels of resolution and appeal within the MCO's grievance system prior to requesting a hearing with HCA. See WAC 182-538-110.
3. If an MCO enrollee does not agree with the MCO's resolution of the enrollee's appeal, the enrollee may request a hearing orally or in writing to the contact information on the written notice. The enrollee must request the hearing within one hundred twenty calendar days of the date of receipt of the MCO's notice of resolution of the MCOs appeal process.
   1. An enrollee may request continuation of services pending the outcome of a hearing related to the termination, suspension, or reduction of a previously authorized service.
   2. To receive continuation of services pending the outcome of the hearing, the enrollee must request a hearing and request to continue services within ten days of the date of the MCO's notice of the resolution of the appeal. See WAC 182-538-110 for additional requirements related to continuation of services.
4. The entire appeal and hearing process, including the MCO appeal process, must be completed within ninety calendar days of the date the MCO enrollee filed the appeal with the MCO, not including the number of days the enrollee took to subsequently file for a hearing.
5. Expedited hearing process.
   1. The office of administrative hearings (OAH) must establish and maintain an expedited hearing process when the enrollee or the enrollee's representative requests an expedited hearing and OAH determines that the time taken for a standard resolution of the claim could seriously jeopardize the enrollee's life or health and ability to attain, maintain, or regain maximum function.
   2. When approving an expedited hearing, OAH must issue a hearing decision as expeditiously as the enrollee's health condition requires, but not later than three business days after receiving the case file and information from the MCO regarding the action and MCO appeal.
   3. When denying an expedited hearing, OAH must give prompt oral notice to the enrollee followed by written notice within two calendar days of the request and change the hearing to the standard time frame.
6. Parties to the hearing include HCA, the MCO, the enrollee, and the enrollee's representative or the representative of a deceased enrollee's estate.
7. Any party that disagrees with the initial order may request a review by an HCA review judge in accordance with WAC 182-526-0560 through 182-526-0600.
8. If an enrollee disagrees with the initial order, the enrollee may request review in accordance with subsection (7) of this section, or an independent review (IR) by an independent review organization (IRO) in accordance with RCW 48.43.535. The enrollee must request the IR within twenty-one calendar days of the date of mailing the initial order. A timely submitted request for an IR stays any review requested pursuant to subsection (7) of this section.
9. Any party that disagrees with the IR decision may request a review by an HCA review judge in accordance with WAC 182-526-0560 through 182-526-0600 within twenty-one calendar days of the date of mailing of the IR decision.
10. When an initial order or an IR decision is appealed to an HCA review judge, the review judge issues the final order.

WAC 182-526-0195 Prehearing conferences.

Effective September 27, 2021

1. Unlike a prehearing meeting, a prehearing conference is a formal proceeding conducted on the record by an administrative law judge (ALJ) to address issues and prepare for a hearing.
   1. The ALJ must make an audio record of the prehearing conference.
   2. An ALJ may conduct the prehearing conference in person, by telephone, or in any other manner acceptable to the parties.
2. All parties must attend the prehearing conference. If the party who requested the hearing does not attend the prehearing conference, the ALJ may enter an order of default and an order dismissing the hearing.
3. The ALJ may require a prehearing conference. Any party may request a prehearing conference.
4. The ALJ must grant the appellant's, and may grant the managed care organization's or the agency representative's, first request for a prehearing conference if it is filed with the office of administrative hearings (OAH) at least seven business days before the scheduled hearing date.
5. When the ALJ grants a party's request for a prehearing conference, the ALJ must continue the previously scheduled hearing when necessary to comply with notice requirements in this section.
6. The ALJ may grant additional requests for prehearing conferences.
7. The office of administrative hearings (OAH) must schedule prehearing conferences for all cases which concern:
   1. The department's division of residential care services under Title XIX of the federal Social Security Act.
   2. Provider and vendor overpayment hearings.
   3. Estate recovery and predeath liens.
8. During a prehearing conference the parties and the ALJ may:
   1. Simplify or clarify the issues to be decided during the hearing;
   2. Agree to the date, time, and place of the hearing;
   3. Identify any accommodation or safety issues;
   4. Agree to postpone the hearing;
   5. Allow the parties to make changes in their own documents, including the notice or the hearing request;
   6. Agree to facts and documents to be entered during the hearing;
   7. Set a deadline to exchange names and phone numbers of witnesses and documents before the hearing;
   8. Schedule additional prehearing conferences;
   9. Resolve the dispute;
   10. Consider granting a stay if authorized by law or program rule; or
   11. Rule on any procedural issues and substantive motions raised by any party.
9. After the prehearing conference, the ALJ must enter a written order describing:
   1. The actions taken at the prehearing conference;
   2. Any changes to the documents;
   3. A statement of the issue or issues identified for the hearing;
   4. Any agreements reached; and
   5. Any ruling of the ALJ.
10. OAH must serve the prehearing order on the parties at least fourteen calendar days before the scheduled hearing.
11. A party may object to the prehearing order by notifying OAH in writing within ten calendar days after the mailing date of the order. The ALJ must issue a ruling on the objection within five days from the date a party files an objection.
12. If no objection is made to the prehearing order, the order determines how the hearing is conducted, including whether the hearing will be in person or held by telephone conference or other means, unless the ALJ changes the order for good cause.
13. The ALJ may take further appropriate actions to address other concerns raised by the parties.

WAC 182-526-0185 Settlement agreements.

Effective March 16, 2017

1. If the parties resolve the dispute during the prehearing meeting and put it in writing or present the agreement to an administrative law judge (ALJ), the agreement may be legally enforceable.
2. If the parties want the ALJ to consider any agreements or stipulations made at the prehearing meeting, the parties must present them to the ALJ either before or during the hearing.
3. If all the issues are not resolved in the prehearing meeting, the parties may request a prehearing conference before an ALJ or go to the scheduled hearing. The ALJ may also order a prehearing conference.
4. If all the issues are resolved and the settlement agreement is in writing and signed by both parties, or presented orally by both parties to the ALJ, the ALJ enters the settlement agreement into the record and the agreement constitutes a withdrawal of the appellant's hearing request.

WAC 182-526-0156 Legal assistance in the hearing process.

Effective February 1, 2013

1. The health care authority (HCA), HCA's authorized agents, and the office of administrative hearings (OAH) will not pay for an attorney for another party.
2. If a party wants an attorney to represent him or her and cannot afford one, community resources may be available to assist that party. These legal services may be free or available at a reduced cost. HCA, HCA's authorized agent, or OAH can provide information about who to contact for legal assistance.
3. Information about legal assistance can also be found at http://www.oah.wa.gov/.

WAC 182-526-0155 Appellant's representation in the hearing.

Effective July 27, 2019

1. Appellants may act as their own representative or may choose to have someone represent them including, but not limited to, a friend, relative, community advocate, attorney or paralegal.
2. All parties, including the health care authority (HCA) and their representatives, must provide their name, address, and telephone number to the office of administrative hearings (OAH) and all other parties prior to the hearing.
3. The administrative law judge (ALJ) may require an appellant's representative to file a written notice of appearance, limited notice of appearance, or other documentation authorizing the representative to appear on behalf of the appellant.
4. In cases involving confidential information, the representative must file a legally sufficient signed written consent or release of information document with HCA or HCA's authorized agent.
5. If an appellant is represented by an attorney admitted to practice law in Washington state, the attorney must file a notice of appearance or limited notice of appearance and a notice of withdrawal if the attorney stops representing the appellant before the hearing process ends.
6. HCA allows an exception to the requirement to file a notice of appearance in subsection (5) of this section when an appellant is represented by an attorney admitted to practice law in Washington
   state, and that attorney originally requested the appellant's hearing under WAC 182-526-0095. If the attorney stops representing the appellant before the hearing process ends, the requirement to file a notice of withdrawal still applies.
7. The following restrictions apply to an appellant's representative:
   1. HCA and HCA's authorized agents do not pay for an appellant's representation.
   2. OAH does not pay for an appellant's representation.
   3. The following people may not act as an appellant's representative in a hearing under this chapter:
      1. An employee of HCA;
      2. HCA's authorized agent;
      3. An employee of the department of social and health services (DSHS);
      4. An employee of the department of children, youth, and families (DCYF);
      5. An employee of OAH; or
      6. Anyone under eighteen years of age.

WAC 182-526-0150 Hearing decisions involving limited-English-proficient parties.

Effective February 1, 2013

1. When an interpreter is used at a hearing, the administrative law judge must explain that the decision is written in English and that the office of administrative hearings (OAH) will provide an interpreter for a sight translation of the decision at no cost to that party.
2. OAH must provide the party needing sight translation services information about how to obtain those services. Information about how to access sight translations must be attached to the decision or order.
3. OAH or the board of appeals must send a copy of a decision or order to an interpreter for use in sight translation.

WAC 182-526-0145 Interpreter requirements.

Effective February 1, 2013

1. Interpreters must:
   1. Use the interpretive mode that the parties, the person with hearing loss, the interpreter, and the administrative law judge (ALJ) consider the most accurate and effective;
   2. Interpret statements made by the parties and the ALJ;
   3. Not disclose information about the hearing without the written consent of the parties; and
   4. Not comment on the hearing or give legal advice.
2. The ALJ must allow enough time for all interpretations to be made and understood.
3. The ALJ may make a video recording of a hearing and use it as the official transcript for hearings involving a person with hearing loss.

WAC 182-526-0140 Waiving interpreter services.

Effective February 1, 2013

1. If one of the parties is limited-English-proficient (LEP), that party may ask to waive interpreter services.
2. The request must be in writing or through a qualified interpreter on the record.
3. The administrative law judge must determine if the waiver has been knowingly and voluntarily made.
4. The party may withdraw their waiver at any time before or during the hearing.

WAC 182-526-0135 Interpreters.

Effective March 16, 2017

1. The office of administrative hearings (OAH) must provide a qualified interpreter to assist any person at no charge who:
   1. Has limited-English-proficiency; and
   2. Is a party or witness in a hearing.
2. OAH may hire or contract with persons to interpret at hearings.
3. The following persons may not be used as interpreters at a hearing:
   1. A relative of any party;
   2. Health care authority (HCA) employees; or
   3. HCA authorized agents.
4. The administrative law judge (ALJ) must determine, at the beginning of the hearing, if an interpreter can accurately interpret all communication for the person requesting the service. To do so, the ALJ considers the interpreter's:
   1. Ability to meet the needs of the person with hearing loss or limited-English-speaking person;
   2. Education, certification, and experience;
   3. Understanding of the basic vocabulary and procedures involved in the hearing; and
   4. Ability to be impartial.
5. The parties or their representatives may question the interpreter's qualifications and ability to be impartial.
6. If at any time before or during the hearing the interpreter does not provide accurate and effective communication, OAH must provide another interpreter.

WAC 182-526-0120 Interpreter services for hearings.

Effective February 1, 2013

If the party requesting the hearing needs an interpreter because party or its witness is a person with limited English-proficiency, the office of administrative hearings will provide an interpreter at no cost to that party.