Section 182-22-330. How to appeal a managed health care system (MHCS) decision nonsubsidized enrollees.

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(1) Nonsubsidized enrollees who are appealing an MHCS decision, including decisions related to coverage disputes; denial of claims; benefits interpretation; or resolution of complaints must follow their MHCS's complaint/appeals process.

(2) Each MHCS must maintain a complaint/appeals process for enrollees and must provide enrollees with instructions for filing a complaint and/or appeal. This complaint/appeals process must comply with the requirements of chapters 48.43 RCW and 284-43 WAC.

(3) On the request of the enrollee, the HCA may assist an enrollee by:

(a) Attempting to informally resolve complaints against the enrollee's MHCS;

(b) Investigating and resolving MHCS contractual issues; and

(c) Providing information and assistance to facilitate review of the decision by an independent review organization.

[Statutory Authority: Chapter 70.47 RCW. WSR 11-15-020, § 182-22-330, filed 7/8/11, effective 8/8/11; WSR 10-24-062 (Order 10-03), § 182-22-330, filed 11/30/10, effective 12/31/10.]

Chapter 70.47 RCW. WSR 11-15-020, § 182-22-330, filed 7/8/11, effective 8/8/11; WSR 10-24-062 (Order 10-03), § 182-22-330, filed 11/30/10, effective 12/31/10.

Rules

284-43,

                    
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