Members

Health Care Authority (HCA) Board of Appeals Review Judge Decision

If you do not agree with the Independent Review Organization’s (IRO) decision, you can ask for a final review of your case by the HCA Board of Appeals Review Judge. You must ask for this within 21 calendar days after the IRO decision is mailed. The decision of the HCA Review Judge is final.

How do I ask for a final review by the HCA Board of Appeals?

  • Call the Board at (360) 725-0910, or (844) 728-5212 (toll-free);
  • Write your final review request and fax it to (360) 507-9018;
  • Or write your final review request and mail it to:

Health Care Authority Board of Appeals
PO Box 42700
Olympia, WA 98504-2700

 

OTHER INFORMATION

Billed for services: If you get a bill for health care services, call (800) 869-7165, TTY 711.

 

Second Opinion: At any time, you can get a second opinion about your health care or condition. Call (800) 869-7165, TTY 711, to find out how to get a second opinion.

 

Children under 21: The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are covered by Medicaid. MCO’s are required to provide any additional health care services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct, or reduce illnesses and conditions that are discovered. When a medically necessary covered service is denied, appeal rights will be provided. For children under the age of 21, the Exception to Rule (ETR) process does not apply.

 

Non-Covered Benefit

Exception to Rule: You or your provider may ask Molina Healthcare to approve a service that is not a covered benefit. For adults, this is called an Exception to Rule (ETR). 

  • It must be asked for before you get the service.

  • To be approved, your provider must give us documentation that your condition is so different from most people.

  • No other covered, less costly service will meet your need.

  • The request must meet the rules in Washington Administrative Code (WAC) 182-501-0160 for approval.

    ETR decisions are final and cannot be appealed.


    Appeal:     You may ask for an appeal, State Administrative Hearing, and then Independent Review to make sure we correctly determined the service is not covered. You can ask for an appeal at the same you or your provider asks for an Exception to Rule.

     

    Limited Benefit: 

    Limitation Extension: Your provider may ask Molina Healthcare to approve more services for you than your benefit package allows. It may be more in scope, number, length of time, or how often a service is provided. An example is more adult physical therapy visits than the 12 visits the benefit allows. This is called a Limitation Extension (LE). To be approved, it must meet the rules in Washington Administrative Code (WAC) 182-501-0169:

  • It must be asked for before you get more of the service.

  • Your condition must show it is improving due to the services you have already received. 

  • Your condition must show it will likely continue to improve with more services, and that it will likely worsen without continued services

    You can ask for an appeal at the same time as your provider asks for a Limitation Extension. 

     

    Funding for some services is limited by available money:  If you receive services that are paid for by Medicaid dollars, you have the right to appeal a decision that stops or limits those services. Some services are paid for with State-only or Federal block grant dollars. If the State-only or block grant money runs out, we cannot approve the service for you even if we agree the services are needed. There is no appeal process if a service is ended due to State-Only or block grant money running out. You will be notified if this situation applies to you.