WAC 182-526-0260 Amending the health care authority or managed care organization notice

WAC 182-526-0260 Amending the health care authority or managed care organization notice.

Effective February 1, 2013

  1. The administrative law judge (ALJ) must allow the health care authority (HCA), HCA’s authorized agent or a managed care organization (MCO) to amend (change) the notice of an action before or during the hearing to match the evidence and facts.
  2. HCA, HCA’s authorized agent or MCO must put the change in writing and deliver a copy to the ALJ and all parties.
  3. The ALJ must offer to continue (postpone) the hearing to give the parties more time to prepare or present evidence or argument if there is a substantive change from the earlier notice.
  4. If the ALJ grants a continuance, the office of administrative hearings must serve a new hearing notice at least fourteen calendar days before the hearing date.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-526-0250 Time requirements for notices issued by the office of administrative hearings.

WAC 182-526-0250 Time requirements for notices issued by the office of administrative hearings.

Effective March 16, 2017

  1. The office of administrative hearings (OAH) must serve a notice of hearing on all parties and their representatives at least fourteen calendar days before the hearing date.
  2. If OAH schedules a prehearing conference, the OAH must serve a notice of prehearing conference to the parties and their representatives at least seven business days before the date of the prehearing conference except:
    1. OAH or an administrative law judge (ALJ) may change a scheduled hearing into a prehearing conference and provide less than seven business days' notice of the prehearing conference; and
    2. OAH may give less than seven business days' notice if the only purpose of the prehearing conference is to consider whether to grant a continuance under WAC 182-526-0280 or 182-526-0282, as applicable.
  3. OAH must reschedule the hearing if necessary to comply with the notice requirements in this section, unless the parties agree to waive notice requirements.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-526-0245 Disqualifying an administrative law judge or review judge.

WAC 182-526-0245 Disqualifying an administrative law judge or review judge.

Effective March 16, 2017

  1. An administrative law judge (ALJ) or review judge may be disqualified for bias, prejudice, or conflict of interest, or if one of the parties or a party's representative has ex parte contact with the ALJ or review judge.
  2. Ex parte contact means any written or oral communication with the ALJ or review judge about something related to the hearing when the other parties are not present. Procedural questions are not considered an ex parte contact. Examples of procedural questions include clarifying the hearing date, time, or location, or asking for directions to the hearing location.
  3. To request disqualification of an ALJ or review judge, a party must file a written petition for disqualification consistent with RCW 34.05.425 explaining why the ALJ or review judge should be disqualified. A party must promptly file the petition upon discovery of possible bias, conflict of interest, or ex parte contact.
  4. A party must deliver the petition to the ALJ or review judge assigned to the case. That ALJ or review judge must decide whether to grant or deny the petition and must state the facts and reasons for the decision.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-526-0240 Filing a motion of prejudice.

WAC 182-526-0240 Filing a motion of prejudice.

Effective March 16, 2017

  1. A party requesting a different administrative law judge (ALJ) may do so by filing a written motion of prejudice consistent with RCW 34.12.050. A party must file the motion with the office of administrative hearings (OAH) before the ALJ rules on a discretionary issue in the case, admits evidence, or takes testimony. The motion must include an affidavit or sworn statement under penalty of perjury supporting the party's claim that the ALJ cannot hear the case fairly.
  2. Rulings that are not considered discretionary rulings for purposes of this section include, but are not limited to rulings that:
    1. Grant or deny a request for a continuance; or
    2. Grant or deny a request for a prehearing conference.
  3. A party must send the motion of prejudice to the chief ALJ at OAH headquarters and must send a copy to the OAH field office where the ALJ is assigned. The address of OAH headquarters is provided in WAC 182-526-0025 (1).
  4. A party may make an oral motion of prejudice at the beginning of the hearing or prehearing conference before the ALJ rules on a discretionary issue in the case, admits evidence, or takes testimony if:
    1. OAH did not assign an ALJ at least five business days before the date of the hearing or prehearing conference; or
    2. The OAH changed the assigned ALJ within five business days of the date of the hearing.
  5. The first request by each party for a different ALJ is automatically granted. The chief ALJ or a designee grants or denies any later requests.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-526-0230 Assigning an administrative law judge to a hearing.

WAC 182-526-0230 Assigning an administrative law judge to a hearing.

Effective March 16, 2017

  1. The office of administrative hearings (OAH) assigns an administrative law judge (ALJ) at least five business days before the hearing, except when the hearing is expedited.
  2. A party may ask which ALJ is assigned to the hearing by calling or writing the OAH field office listed on the notice of hearing.
  3. If requested by a party, OAH must send the name of the assigned ALJ to the party by e-mail or in writing at least five business days before the party's scheduled hearing date.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-526-0221 HCA index of significant decisions.

WAC 182-526-0221 HCA index of significant decisions.

Effective March 16, 2017

  1. A final order may be relied on, used, or cited as precedent by a party if the final order has been indexed in the index of significant decisions maintained by the health care authority (HCA).
  2. The index of significant decisions is available to the public at www.hca.wa.gov/about-hca/significant-decisions. For information on how to obtain a copy of the index, contact the HCA hearing representative.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-526-0220 Rules and laws an administrative law judge and review judge must apply when conducting a hearing or making a decision

WAC 182-526-0220 Rules and laws an administrative law judge and review judge must apply when conducting a hearing or making a decision.

Effective February 1, 2013

  1. Administrative law judges (ALJs) and review judges must first apply the applicable program rules adopted in the Washington Administrative Code (WAC).
  2. If no program rule applies, the ALJ or review judge must decide the issue according to the best legal authority and reasoning available, including federal and Washington state constitutions, statutes, regulations, and court decisions.
  3. When applying program rules regarding the substantive rights and responsibilities of the parties (such as eligibility for services, benefits, or a license), the ALJ and review judge must apply the program rules in effect on the date of the health care authority (HCA) action, unless otherwise required by other rule or law. If HCA amends its notice of action, the ALJ or review judge must apply the rules in effect on the date the action was taken, unless otherwise required by other rule or law.
  4. When applying procedural rules, the ALJ and review judge must apply the rules that are in effect on the date the procedure is followed.
  5. Program rules determine the amount of time HCA or HCA’s authorized agent has to process an application for services, benefits, or a license.
  6. The ALJ and review judge must apply the rules in this chapter beginning on the date each rule is effective.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-526-0216 The authority of the administrative law judge and the review judge is limited

WAC 182-526-0216 The authority of the administrative law judge and the review judge is limited.

Effective February 1, 2013

  1. The authority of the administrative law judge and the review judge is limited to those powers granted by statute or rule. The ALJ and the review judge do not have any inherent or common law powers.
  2. Neither an administrative law judge nor a review judge may decide that a rule is invalid or unenforceable. Only a court may decide this issue.
  3. If the validity of a rule is raised during the hearing, the ALJ or review judge may allow only argument for court reviews.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-526-0215 Authority of the administrative law judge when conducting a hearing.

WAC 182-526-0215 Authority of the administrative law judge when conducting a hearing.

Effective March 16, 2017

  1. The administrative law judge (ALJ) must hear and decide the issues de novo (anew) based on the evidence presented and admitted into the record during the hearing.
  2. As needed, the ALJ may:
    1. Determine the order for presenting evidence;
    2. Issue subpoenas or orders directing witnesses to appear or bring documents;
    3. Rule on objections, motions, and other procedural matters;
    4. Rule on an offer of proof made to admit evidence;
    5. Admit relevant evidence;
    6. Impartially question witnesses to develop the record;
    7. Call additional witnesses and request exhibits to complete the record;
    8. Give the parties an opportunity to cross-examine witnesses or present more evidence against the witnesses or exhibits;
    9. Keep order during the hearing;
    10. Allow or require oral or written argument and set the deadlines for the parties to submit argument or evidence;
    11. Permit others to attend, photograph, or electronically record hearings, but may place conditions to preserve confidentiality or prevent disruption;
    12. Allow a party to waive rights given by chapters 34.05 RCW or 182-526 WAC, unless another law prevents it;
    13. Decide whether a party has a right to a hearing;
    14. Issue protective orders;
    15. Consider granting a stay if authorized by law or HCA rule; and
    16. Take any other action necessary and authorized under these or other rules.
  3. The ALJ administers oaths or affirmations and takes testimony.
  4. The ALJ enters an initial order after the hearing. Initial orders become final orders under WAC 182-526-0525.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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

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.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

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