Washington Medical Coverage: Problem Solving
State & Federal
Medical Programs
Other Programs
Problem Solving
DSHS Administrative Hearings
DSHS Complaint procedures
Basic Health Appeals Procedures
Medicare Appeal process
DSHS Administrative Hearings
Request
If an individual disagrees with an action DSHS has taken (denied benefits or medical services, reduced grant) or disputes a DSHS claim (benefit overpayment) the applicant has the right to a hearing before an Administrative Law Judge (ALJ). An individual can request a hearing from any responsible Department employee. Another way of requesting a hearing is to contact the nearest Office of Administrative Hearings (OAH). Information about OAH offices.
Deadlines
The time limit for appealing most DSHS decisions is 90 days. However, when the decision being appealed is to reduce or terminate benefits, it is important for the recipient to maintain the status quo while the appeal is pending. In order to maintain benefits during the appeal (called “continued benefits”), the hearing must be requested within 10 days of the termination decision. If the 10th day occurs before the end of the month after which the decision takes effect, the recipient can receive continued benefits by requesting a hearing on or before the final day of the month
Representatives and Advocates
An applicant has the right to be represented at a fair hearing. A representative can be an attorney, legal advocate, friend or family member.
The “Hearing Packet”
Clients should make sure that they receive a “fair hearing report” and a copy of all of the Department’s exhibits (documents that the department intends to enter into the record at a fair hearing) well in advance of the hearing date. This information is helpful for the client to prepare for the hearing and to allow the client to fully understand the department’s position in the dispute. If the client does not receive the fair hearing packet in advance of the hearing, he or she can request a continuance so that they have sufficient time to prepare.
Pre-Hearing Meeting
Hearing Coordinators are being asked to complete pre-hearing meetings with clients and, if they are represented, their advocates, in advance of the fair hearing. The pre-hearing meeting is an opportunity to determine whether the dispute can be resolved. It is voluntary, and clients are not required to participate. See WAC 388-02-0175
Pre-Hearing Conference
A Pre-hearing conference is a more formal meeting conducted by the administrative law judge in order to determine if there are procedural issues that need to be addressed in advance of the hearing. Either the Department or the client can request a pre-hearing conference. The client or his or her representative must attend the pre-hearing conference. See WAC 388-02-0195
The Administrative Hearing
Administrative hearings are generally held at the welfare offices (CSOs) or at the Home and Community Services offices, depending upon the issues in the dispute. DSHS is typically represented by the Hearing Coordinator who is also a DSHS employee. If the issue involves denial of medical services, devices or prescription drugs, DSHS is usually represented by an attorney employed by the state Medicaid agency. At the hearing the client and DSHS can present evidence and arguments to support their position. Instead of making a decision on the day of the hearing, the ALJ sends out a written decision to the parties within a few weeks after the hearing.
Request for Reconsideration
Either party to a hearing may request that the ALJ or, in cases subject to review by the Board of Appeals, the Review Judge reconsider portions or all of the hearing decision. The request for reconsideration must be filed within 10 days after the mailing of the hearing or review decision.
Petition for Administrative Review
If either party disagrees with the initial decision made by the Administrative Law Judge in a case involving denial of medical services, devices, or prescription drugs, either party may file a petition for administrative review with the DSHS Board of Appeals (BOA). (Hearing decisions involving program eligibility issues are not subject to BOA review and must be appealed directly to superior court – see below.) The petition must be filed within 21 days of the date of the hearing decision. On review, no new evidence may be submitted and no hearing is held. The BOA Review Judge reviews all the evidence and makes a decision based on the evidence presented at the ALJ hearing.
Appeal to Superior Court
If the client disagrees with the administrative decision, she or he can appeal the decision to Superior Court by filing a petition for judicial review. The client is only able to obtain continued benefits if he or she obtains a “stay” of the administrative decision from the Superior Court judge. The superior court judge makes a decision on the appeal based on review of the administrative record and consideration of the written and oral arguments of the parties.
DSHS Complaint procedures
1. Individuals can file written complaints with their local CSO office regarding any aspect of DSHS services. Complaints must be responded to within 10 days.
Complaints can also be made to:
Director of Community Relations
Washington State Department of Social and Health Services
PO Box 45440
Olympia, Washington 98504
2. DSHS has established a separate office to investigate complaints about racial, ethnic and/or disability discrimination. These complaints should be addressed to: DSHS Division of Access and Equal Opportunity at (800) 521-8060.
Additionally, complaints about race, ethnic or disability discrimination should also be filed with the federal Department of Health and Human Services, Office for Civil Rights, at (800) 362-1710.
3. Requests for assistance with resolving disputes with DSHS can be made at the Medical Assistance Administration’s toll-free number (800) 562-3022. The DSHS Constituent Services number, (800) 865-7801 may also be helpful.
4. Medicaid enrollees who are in a managed care plan (Healthy Options) use a combination of the health insurer’s grievance and appeals procedure, the DSHS fair hearing process (if not satisfied by the insurer’s decision), and the independent review process mandated under the Patients’ Bill of Rights (see below).
Basic Health Appeals Procedures
Health Plan Grievances and Appeals:
The BH health plans, like other commercial health insurers, are required to have grievance and appeals procedures. Additionally, under the state Patients’ Bill of Rights, enrollees have the right to an independent third party review of disputes involving access to medical care and treatment, and the ability to seek judicial review of denials of care that cause harm. For more information about this law, see the website for the Office of the Insurance Commissioner.
Enrollees may request the assistance of Basic Health in pursuing a complaint by calling 1-800-660-9840 or writing to the agency at P.O. Box 42683, Olympia, WA 98504-2683. If you call, make sure to take notes of your conversation including who you spoke to and when. Enrollees can request informal dispute resolution, investigation and resolution of contractual issues with the plan, and information and assistance to facilitate independent review.
Appeals of HCA decisions:
BH enrollees can appeal decisions made by HCA regarding eligibility, premiums, premium adjustments or penalties, enrollment, suspension, disenrollment or a member’s selection of a BH health plan. Appeals must be in writing and must be received by HCA within 30 days of the date of the decision.
Write to
Basic Health Appeals
P.O. Box 42690
Olympia, WA 98504-2690
In order for your appeal to be processed, it must include name address, subscriber ID, daytime phone, summary of the decision and why you believe it is incorrect. Indicate if you need interpretive services or assistance due to a disability.
Appeals are conducted by a hearing officer or by an Appeals Committee, based upon the submitted documents unless HCA and the appealing party agree to hold a hearing, either in person or by telephone. Decisions should be rendered within 60 days of when HCA receives the letter of appeal.
If the appealing party seeks a review of the appeals decision within 30 days of the date of the decision, either a presiding officer of HCA or the Office of Administrative Hearings (in the case of a disenrollment for nonpayment of premiums) will conduct a hearing, similar to the DSHS Fair Hearing process.
Medicare Appeal process
People enrolled in Medicare have the right to file an appeal if they disagree with a decision by Medicare not to pay for a covered service or a decision by their Medicare HMO with which they disagree. Medicare enrollees can call the federal Centers for Medicare and Medicaid Services at (800) 633-4227 for more information on filing appeals of Medicare decisions.
Medicare Part D enrollees may request exceptions and appeals if drugs are denied by the Prescription Drug Plan (PDP). Each PDP has its own exception/appeals process, which can be found through medicare.gov.
SHIBA HelpLine
The State Office of the Insurance Commissioner offers the Statewide Health Insurance Benefits Advisors (SHIBA) HelpLine, a service using trained volunteers to provide education, advocacy and referrals. They are knowledgeable about health insurance, government programs (especially Medicare), prescription drug access, medical billings, etc. They provide help to people pursuing claims or appeals in some situations. The toll-free phone number is 1-800-562-6900.