WAC 182-526-0560 Review of an initial order by a review judge.

Effective March 16, 2017

1. A party who disagrees with the initial order entered by an administrative law judge (ALJ) may request review by a review judge at the board of appeals (BOA).
2. When a review judge reviews an initial order, the review judge does not hold another hearing. See WAC 182-526-0595.
3. Review judges may not review an initial order after the order becomes a final order, except as permitted by WAC 182-526-0580.

WAC 182-526-0555 Process after a party requests a corrected initial order.

Effective March 16, 2017

1. When a party requests a corrected initial order, the administrative law judge (ALJ) must either:
   1. Serve all parties a corrected order within ten calendar days; or
   2. Deny the request in writing within three business days of receiving it.
2. If the ALJ corrects an initial order and a party does not request review, the corrected initial order becomes a final order at 5:00 p.m., twenty-one calendar days after the corrected initial order was served.
3. If the ALJ denies a request for a corrected initial order and a party does not request review, the initial order becomes a final order at 5:00 p.m., twenty-one calendar days after the initial order was served.
4. If the ALJ denies the request for a corrected initial order and the party still wants the initial order corrected, the party must request review by a review judge.
5. Requesting an ALJ to correct the initial order only extends the deadline to request review of the initial order by a review judge if a corrected initial order is subsequently issued.
6. When a party needs more time to request review of an initial order, the party must ask for more time to request review as permitted by WAC 182-526-0580(2).

WAC 182-526-0550 Deadline for a party to request a corrected initial order.

Effective March 16, 2017

1. A party requesting a corrected initial order from the administrative law judge (ALJ) must make the request on or before the tenth calendar day after the order was served.
2. The time period provided in subsection (1) of this section and the time it takes the ALJ to deny the request or make a decision regarding the request for a corrected initial order, do not count against any deadline for a review judge to enter a final order.

WAC 182-526-0545 How a party requests a corrected initial order.

Effective March 16, 2017

1. A party may request that the administrative law judge (ALJ) issue a corrected initial order by calling or writing to the office of administrative hearings field office that held the hearing.
2. When asking for a corrected initial order, the party must identify the clerical error that is claimed.

WAC 182-526-0530 How to correct or appeal an initial order.

Effective February 1, 2013

1. If a party disagrees with an administrative law judge's (ALJ) initial order because of a clerical error, the party may ask for a corrected initial order from the ALJ as provided in WAC 182-526-0540 through 182-526-0555.
2. If a party disagrees with an initial order for a reason other than a clerical error and wants the initial order changed, the party must request review by a review judge as provided in WAC 182-526-0560 through 182-526-0595.

WAC 182-526-0525  When initial orders become final.

Effective March 16, 2017

An initial order becomes a final order at 5:00 p.m. on the twenty-first calendar day after the office of administrative hearings (OAH) serves the initial order, unless:

1. Any party files a request for review of the initial order within twenty-one calendar days of the serving (mailing) of the initial order in accordance with WAC 182-526-0580(1);
2. Any party files a request for extension of the deadline for filing a request for review which is granted by the review judge under WAC 182-526-0580(2); or
3. Any party files a late request for review which is accepted by a review judge in accordance with WAC 182-526-0580(3);
4. A managed care enrollee requests review by an independent review (IR) organization in accordance with RCW 48.43.535 prior to the initial order becoming final or a final order being entered by a review judge. See WAC 182-526-0200 for enrollee appeals.

WAC 182-526-0520 Information which must be included in the ALJ's initial order.

Effective March 16, 2017

In an initial order, the administrative law judge (ALJ) must:

1. Identify the matter as a health care authority appeal;
2. List the name and docket number of the case and the names of all parties and representatives;
3. Make findings concerning the facts used to resolve the dispute based on the hearing record;
4. Explain how the ALJ determined that evidence is credible or not credible when the facts or conduct of a witness is questioned;
5. State the law that applies to the dispute;
6. Apply the law to the facts of the case in the conclusions of law;
7. Discuss the reasons for the decision based on the facts and the law;
8. State the result and remedy ordered;
9. Explain how to request corrections to the initial order or petition for review by the board of appeals (BOA) and provide the deadlines for such requests;
10. State the date the initial order becomes final according to WAC 182-526-0525; and
11. Include any other information required by law or program rules.

WAC 182-526-0512  Contents of the hearing record.

Effective February 1, 2013

1. The administrative law judge must produce a complete official record of the proceedings.
2. The official record must include, if applicable:
   1. Notice of all proceedings;
   2. Any prehearing order;
   3. Any motions, pleadings, briefs, petitions requests, and intermediate rulings;
   4. Evidence received or considered;
   5. A statement of matters officially noticed;
   6. Offers of proof, objections, and any resulting rulings;
   7. Proposed findings, requested orders and exceptions;
   8. A complete audio recording of the entire hearing, together with any transcript of the hearing;
   9. Any final order, initial order, or order on reconsideration; and
   10. Matters placed on the record after an ex parte communication.

WAC 182-526-0500 Hearing record.

Effective March 16, 2017

1. Before the record is closed, the administrative law judge (ALJ) may:
   1. Set another hearing date;
   2. If needed, enter orders addressing limited issues before issuing a hearing decision resolving all issues in the proceeding; or
   3. Give the parties more time to file exhibits or written argument.
2. The record is closed:
   1. At the end of the hearing if the ALJ does not allow more time to file evidence or argument; or
   2. After the deadline for filing evidence or argument is over.
3. After the record is closed:
   1. No more evidence may be admitted without good cause;
   2. The (ALJ) must enter an initial order and the office of administrative hearings (OAH) must serve copies on all of the parties; and
   3. OAH must send the official record of the proceedings to the board of appeals. The record must be complete when it is sent, and include all parts required by WAC 182-526-0512.

WAC 182-501-0070 Health care coverage--Noncovered services.

Effective January 1, 2025

1. The medicaid agency or the agency's designee does not pay for any health care service not listed or referred to as a covered health care service under the medical programs described in WAC 182-501-0060, regardless of medical necessity. For the purposes of this section, health care services includes treatment, equipment, related supplies, and drugs. Circumstances in which clients are responsible for payment of health care services are described in WAC 182-502-0160.
2. This section does not apply to health care services provided as a result of the early and periodic screening, diagnosis, and treatment (EPSDT) program as described in chapter 182-534 WAC.
3. The agency or the agency's designee does not pay for any ancillary health care service(s) provided in association with a noncovered health care service.
4. The following list of noncovered health care services is not intended to be exhaustive. Noncovered health care services include, but are not limited to:
   1. Any health care service specifically excluded by federal or state law;
   2. Acupuncture, Christian Science practice, faith healing, herbal therapy, homeopathy, massage, massage therapy, and sanipractice;
   3. Chiropractic care for adults;
   4. Cosmetic, reconstructive, or plastic surgery, and any related health care services, not specifically allowed under WAC 182-531-0100(4);
   5. Discography;
   6. Ear or other body piercing;
   7. Face lifts or other facial cosmetic enhancements;
   8. Fertility, infertility or sexual dysfunction testing, and related care, drugs, and/or treatment including, but not limited to:
      1. Artificial insemination;
      2. Donor ovum, donor sperm, or gestational carrier;
      3. In vitro fertilization;
      4. Penile implants;
      5. Reversal of sterilization; and
      6. Sex therapy.
   9. Hair transplants;
   10. Epilation (hair removal) and electrolysis not specifically allowed under WAC 182-531-1675;
   11. Marital counseling;
   12. Motion analysis, athletic training evaluation, work hardening condition, high altitude simulation test, and health and behavior assessment;
   13. Nonmedical equipment;
   14. Penile implants;
   15. Prosthetic testicles not specifically allowed under WAC 182-531-1675;
   16. Psychiatric sleep therapy;
   17. Subcutaneous injection filling;
   18. Tattoo removal;
   19. Transport of Involuntary Treatment Act (ITA) clients to or from out-of-state treatment facilities, including those in bordering cities;
   20. Upright magnetic resonance imaging (MRI); and
   21. Vehicle purchase - New or used vehicle.
5. For a specific list of noncovered health care services in the following service categories, refer to the WAC citation:
   1. Ambulance transportation and nonemergent transportation as described in chapter 182-546 WAC;
   2. Dental services as described in chapter 182-535 WAC;
   3. Durable medical equipment as described in chapter 182-543 WAC;
   4. Hearing care services as described in chapter 182-547 WAC;
   5. Home health services as described in WAC 182-551-2130;
   6. Hospital services as described in WAC 182-550-1600;
   7. Health care professional services as described in WAC 182-531-0150;
   8. Prescription drugs as described in chapter 182-530 WAC;
   9. Vision care hardware for clients 20 years of age and younger as described in chapter 182-544 WAC; and
   10. Vision care exams as described in WAC 182-531-1000.
6. A client has a right to request an administrative hearing, if one is available under state and federal law. When the agency or its designee denies all or part of a request for a noncovered health care service(s), the agency or its designee sends the client and the provider written notice, within 10 business days of the date the decision is made, that includes:
   1. A statement of the action the agency or its designee intends to take;
   2. Reference to the specific WAC provision upon which the denial is based;
   3. Sufficient detail to enable the recipient to:
      1. Learn why the agency's or its designee's action was taken; and
      2. Prepare a response to the agency's or its designee's decision to classify the requested health care service as noncovered.
   4. The specific factual basis for the intended action; and
   5. The following information:
      1. Administrative hearing rights;
      2. Instructions on how to request the hearing;
      3. Acknowledgment that a client may be represented at the hearing by legal counsel or other representative;
      4. Instructions on how to request an exception to rule (ETR);
      5. Information regarding agency-covered health care services, if any, as an alternative to the requested noncovered health care service; and
      6. Upon the client's request, the name and address of the nearest legal services office.
7. A client can request an exception to rule (ETR) as described in WAC 182-501-0160.