FAQs about Client Rights

What is a Notice of Action?

A Notice of Action is a denial, suspension, reduction, or termination of your services as defined below:

Denial: The decision by a Prepaid Inpatient Health Plan (PIHP) (i.e. King County Mental Health Plan) not to authorize covered Medicaid mental health services that meet the State Mental Health Division Access to Care Standards or the Medical Assistance Administration memorandum #01-03 MAA, Psychiatric Hospitalization. Or the decision by a PIHP not to authorize covered Medicaid mental health services due to lack of medical necessity. The decision by a Community Mental Health Agency (CMHA) not to provide a covered service is not a denial and can not be appealed. However, an enrollee who objects to a CMHA deciding not to provide a covered service may request a grievance or second opinion.

Suspension: The decision by a PIHP to temporarily stop an enrollee's previously authorized covered Medicaid mental health services. The decision by a CMHA to temporarily stop a covered service is not a suspension.

Reduction: The decision by a PIHP to decrease an enrollee's previously authorized covered Medicaid mental health services. The decision by a CMHA to decrease a covered service is not a reduction.

Termination: The decision by a PIHP to stop an enrollee's previously authorized covered Medicaid mental health services. The decision by a CMHA to stop a covered service is not a termination.

If one of the above events occurs, you will get a written Notice of Action. You may file an appeal whenever you get a Notice of Action.

What is an appeal?

An appeal is a formal complaint to a PIHP about an action.

Here are the steps in the appeal process:

1. To start an appeal, contact the PIHP that sent you the Notice of Action you wish to appeal. You must start the appeal within 20 days of receiving the Notice.

2. You may request assistance with your appeal from your PIHP's Ombuds service. See the last section of this booklet for the telephone number of the Ombuds service in your PIHP. Interpreter and TTY/TDD services are available to help you, if needed. You may also receive help from your community mental health agency or anyone else you choose.

3. You may start an appeal with a phone call or a letter. If you choose to start with a phone call, you must also send a letter within 7 days unless you are requesting a fast appeal (also called an expedited appeal). Please include in your letter your name, how we can best contact you, the reason for your appeal, and any evidence you wish to submit.

4. You may request a fast appeal if you or your mental health care provider believes that a longer time for resolution would jeopardize your ability to maintain or regain maximum functioning. If your request for a fast appeal is granted, your PIHP will make a decision about your appeal within three working days. If the PIHP takes additional time without your request, you will be notified of the reason for the delay. If your request for a fast appeal is not granted, your PIHP will promptly notify you that your appeal will be decided within the usual 45-day timeframe.

5. When your PIHP receives your appeal, you will get a letter or phone call acknowledging its receipt within one working day. If you choose, your PIHP will allow you 72 hours to informally discuss your appeal with the PIHP before you decide to continue the appeal process.

6. During the appeal process, you and anyone helping you can look at your treatment and other records to help you prepare your appeal.

7. Your appeal will be considered by persons who have not been previously involved with your Action and who have the proper training.

8. While your appeal is under consideration, you may request to continue your services, if:
• Your appeal is filed timely;
• Your appeal involves the reduction, suspension or termination of previously authorized covered Medicaid mental health services;
• Your covered Medicaid mental health services were ordered by the CMHA;
• The current period covered by the authorization has not expired; and
• You have requested a continuation of services.

If the decision is not your favor, you may be asked to pay for the services you received during the appeal.

9. Unless you request a fast appeal, your PIHP will make a decision about your appeal within 45 days from the day you started your appeal. In some instances, additional time may be taken if you request it or if it is in your best interest. If the PIHP takes additional time without your request, you will be notified of the reason for the delay.

10. You will receive a written statement of your PIHP's decision.

11. If you are unhappy with the decision regarding your appeal, you may ask for additional consideration of your appeal from the state Office of Administrative Hearings. An administrative hearing, also known as a fair hearing, is a complaint to the State Office of Administrative Hearings (OAH). See below for information on Fair Hearings.

12. After your appeal is resolved, the PIHP and CMHA must keep any records about your appeal separate from your treatment records in a confidential file.

What is a Fair Hearing?

If you are unhappy with the decision regarding your PIHP appeal, you may ask for additional consideration of your appeal from the state Office of Administrative Hearings (OAH). An administrative hearing, also known as a fair hearing, results from a complaint to the OAH. The OAH is an independent part of state government. They are not part of the Department of Social and Health Services (DSHS), the Mental Health Division (MHD), or any PIHP. The OAH decision about your appeal must be carried out by the MHD, the PIHP, and your CMHA. You may have an Ombuds represent or assist you with the hearing at no cost. A lawyer or anybody you choose at your own expense may also represent you. You must ask for an administrative hearing within certain time limits. You should consult the Ombuds or somebody who knows about the time limits.

Note: In some situations, an enrollee may request a state fair hearing before filing an appeal with a PIHP. This is allowed when there has been a violation of state rules. Examples are: the failure of a PIHP to authorize services in a timely manner or to process an appeal according to the required timelines. You may call the OAH or your Ombuds if you feel your complaint may qualify for a state fair hearing prior to your PIHP reviewing it.

If you want to ask the Office of Administrative Hearings to review your complaint, you can send a request to:

Office of Administrative Hearings
P.O. Box 42489
Olympia, WA 98504
The toll-free telephone number is: 1-800-583-8271.

There are several local offices of OAH. Your case will be assigned to one near your home. If an in-person hearing is needed, it will be held in a location close to you.