Section 388-877-0670. Appeal process.

(1) The appeal process is used by an individual to ask the behavioral health organization (BHO) to review an action that the BHO has communicated on a written notice of action (see WAC 388-877-0665). An individual's representative may appeal an action with the individual's written consent. If a written notice of action was not received, an appeal may still be filed.

(2) The individual requesting review of an action must file an appeal and receive a notice of the resolution from the BHO before requesting an administrative hearing.

(3) The appeal process can be:

(a) Standard as described in subsection (6) of this section; or

(b) Expedited if the criteria in subsection (7) of this section are met.

(4) The appeal process must:

(a) Provide an individual a reasonable opportunity to present evidence and allegations of fact or law in person as well as in writing. The BHO must inform the individual of the limited time available.

(b) Provide the individual opportunity, before and during the appeal process, to examine the individual's clinical record, including medical records and any other documents and records considered during the appeal process.

(c) Include the following, as applicable, as parties to the appeal:

(i) The individual, the individual's representative, or both; or

(ii) The legal representative of a deceased individual's estate.

(5) The BHO must ensure that the persons who make decisions on an appeal:

(a) Were not involved in any previous level of review or decision making; and

(b) Are mental health or chemical dependency professionals who have appropriate clinical expertise in the type of behavioral health service involved in the appeal.

(6) Standard appeal process. The standard appeal process includes the following:

(a) Standard appeals for actions communicated on a notice of action-continued services not requested. An individual who disagrees with a decision or action communicated on a notice of action may file an appeal orally or in writing. An oral filing of an appeal must be followed with a written and signed appeal. All of the following apply:

(i) The individual must file the appeal within ninety calendar days from the date on the notice of action.

(ii) The BHO must confirm receipt of the appeal in writing within five business days.

(iii) The BHO must send the individual a written notice of the resolution within forty-five calendar days of receiving the appeal. This timeframe may be extended up to fourteen additional days if the individual requests an extension or the BHO can demonstrate that it needs additional information and that the added time is in the individual's interest. The written notice of the resolution must include:

(A) The BHO's decision;

(B) The reason for the decision; and

(C) The right to request an administrative hearing if the individual disagrees with the decision. The hearing must be requested within ninety calendar days from the date on the notice of the resolution.

(b) Standard appeals for termination, suspension, or reduction of previously authorized services—continued services requested. An individual receiving a notice of action from the BHO that terminates, suspends, or reduces previously authorized services may file an appeal orally or in writing and request continuation of those services pending the BHO's decision on the appeal. An oral filing of an appeal and request for continuation of services must be followed with a written and signed appeal and include a written request for continuation of services pending the BHO's decision on the appeal. All of the following apply:

(i) The individual must:

(A) File the appeal with the BHO on or before the later of the following:

(I) Within ten calendar days of the date on the notice of action; or

(II) The intended effective date of the BHO's proposed action.

(B) Request continuation of services.

(ii) The BHO must:

(A) Confirm receipt of the appeal and the request for continued services with the individual orally or in writing within five business days;

(B) Send a notice in writing that follows up on any oral confirmation made; and

(C) Include in the notice that if the appeal decision is not in favor of the individual, the BHO may recover the cost of the behavioral health services provided pending the BHO decision.

(iii) The BHO's written notice of the resolution must contain:

(A) The BHO's decision on the appeal;

(B) The reason for the decision; and

(C) The right to request an administrative hearing if the individual disagrees with the decision and include the following timeframes:

(I) Within ten calendar days from the date on the notice of the resolution if the individual is asking that services be continued pending the outcome of the hearing.

(II) Within ninety calendar days from the date on the notice of the resolution if the individual is not asking for continued services.

(7) Expedited appeal process. If an individual or the individual's behavioral health provider feels that the time taken for a standard resolution of an appeal could seriously jeopardize the individual's life or health and ability to attain, maintain, or regain maximum function, an expedited appeal and resolution of the appeal can be requested. If the BHO denies the request for the expedited appeal and resolution of an appeal, it must transfer the appeal to the timeframe for standard resolutions under subsection (6) of this section, and make reasonable efforts to give the individual prompt oral notice of the denial and follow up within two calendar days with a written notice.

(a) Both of the following apply to expedited appeal requests:

(i) The action taken on the notice of action is for denial of a requested service, termination, suspension, or reduction of previously authorized behavioral health services; and

(ii) The appeal must be filed with the BHO, either orally or in writing, within:

(A) Ten calendar days of the BHO's mailing the written notice of action that communicated the action, or the intended effective date of the BHO's proposed action, if the individual is requesting continued benefits; or

(B) Twenty calendar days from the date on the BHO's written notice of action that communicated the action if the individual is not requesting continued benefits.

(b) The BHO must:

(i) Confirm receipt of the request for an expedited appeal in person or by telephone.

(ii) Send the individual a written notice of the resolution within three business days of receiving the request for an expedited appeal.

(c) The BHO may extend the timeframes up to fourteen additional days if the individual requests an extension or the BHO can demonstrate it needs additional information and that the added time is in the individual's interest.

(8) Duration of continued services during the appeal process. When an individual has requested continued behavioral health services pending the outcome of the appeal process and the criteria in this section have been met, the BHO ensures the services are continued until one of the following occurs:

(a) The individual withdraws the appeal.

(b) The BHO provides a written notice of the resolution that contains a decision that is not in favor of the individual and the individual does not request an administrative hearing within ten days from the date the BHO mails the notice. (See WAC 388-877-0675, Administrative Hearings, for rules on duration of continued services during the administrative hearing process.)

(c) The time period of a previously authorized service has expired.

(d) A behavioral health treatment service limit of a previously authorized service has been fulfilled.

(9) Recovery of the cost of behavioral health services in adverse decisions of appeals. If the final written notice of the resolution of the appeal is not in favor of the individual, the BHO may recover the cost of the behavioral health services furnished to the individual while the appeal was pending to the extent that they were provided solely because of the requirements of this section.

(10) The BHO must maintain full records of all appeals and ensure an individual's records are:

(a) Kept for six years after the completion of the appeal process;

(b) Made available to the department upon request as part of the state quality strategy;

(c) Kept in confidential files separate from the individual's clinical record; and

(d) Not disclosed without the individual's written permission, except to the department or as necessary to resolve the appeal.

[Statutory Authority: RCW 70.02.290, 70.02.340, 70.96A.040(4), 71.05.560, 71.24.035 (5)(c), 71.34.380, and 2014 c 225. WSR 16-13-087, § 388-877-0670, filed 6/15/16, effective 7/16/16.]

RCW 70.02.290, 70.02.340, 70.96A.040(4), 71.05.560, 71.24.035 (5)(c), 71.34.380, and 2014 c 225. WSR 16-13-087, § 388-877-0670, filed 6/15/16, effective 7/16/16.

Rules

388-877-0665,388-877-0675,