WSR 12-15-015

PERMANENT RULES

HEALTH CARE AUTHORITY


(Medicaid Program)

[ Filed July 10, 2012, 11:25 a.m. , effective September 1, 2012 ]


Effective Date of Rule: September 1, 2012.

Purpose: The proposed rules require providers of durable medical equipment (DME), supplies, and related services to be medicare-enrolled providers in order to also receive payment under Washington state's medicaid program. This rule applies to newly enrolled DME providers and current DME providers upon revalidation of their enrollment in accordance with 42 C.F.R. 455.414.

Citation of Existing Rules Affected by this Order: Amending WAC 182-502-0010 and 182-543-2000.

Statutory Authority for Adoption: RCW 41.05.021.

Other Authority: Affordable Care Act (ACA) - 76 Fed. Reg. 5862, 42 C.F.R. Parts 405, 424, 447, 455, 457, and 498.

Adopted under notice filed as WSR 12-10-067 on May 1, 2012.

Changes Other than Editing from Proposed to Adopted Version: WAC 182-543-2000 (1)(c) DME and related supplies, prosthetics, orthotics, medical supplies and related services -- Eligible providers and provider requirements, removed the requirement for prosthetics and orthotics providers to be enrolled with medicare.

(c) Prosthetics and orthotics providers who are enrolled with medicare and licensed by the Washington state department of health in prosthetics and orthotics. Medical equipment dealers and pharmacies that do not require state licensure to provide selected prosthetics and orthotics may be paid for those selected prosthetics and orthotics only as long as the medical equipment dealers and pharmacies meet the medicare enrollment requirement;

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 2, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 2, Repealed 0.

Date Adopted: July 10, 2012.

Kevin M. Sullivan

Rules Coordinator

OTS-4689.1


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-502-0010   When the ((department)) medicaid agency enrolls.   (1) Nothing in this chapter obligates the ((department)) agency to enroll any eligible ((healthcare)) health care professional, ((healthcare)) health care entity, supplier or contractor of service who requests enrollment.

(2) To enroll as a provider with the ((department)) medicaid agency, a ((healthcare)) health care professional, ((healthcare)) health care entity, supplier or contractor of service must, on the date of application:

(a) Be currently licensed, certified, accredited, or registered according to Washington state laws and rules. Persons or entities outside of Washington state, see WAC ((388-502-0120)) 182-502-0120;

(b) Be enrolled with medicare, when required in specific program rules;

(c) Have current professional liability coverage, individually or as a member of a group;

(((c))) (d) Have a current federal drug enforcement agency (DEA) certificate, if applicable to the profession's scope of practice;

(((d))) (e) Meet the conditions in this chapter and other chapters regulating the specific type of ((healthcare)) health care practitioner;

(((e))) (f) Sign, without modification, a core provider agreement (CPA) and debarment form (((DSHS)) 09-048) or a contract with the ((department)) agency. (Note: Section 13 of the CPA, ((DSHS)) 09-048 (REV. 08/2005), is hereby rescinded. The ((department)) medicaid agency and each provider signing a core provider agreement will hold each other harmless from a legal action based on the negligent actions or omissions of either party under the terms of the agreement.);

(((f))) (g) Agree to accept the payment from the ((department)) medicaid agency as payment in full (in accordance with 42 C.F.R. 447.15 acceptance of state payment as payment in full and WAC ((388-502-0160)) 182-502-0160 billing a client);

(((g))) (h) Fully disclose ownership and control information requested by the ((department)) agency. If payment for services is to be made to a group practice, partnership, or corporation, the group, partnership, or corporation must enroll and obtain a CPA number to be used for submitting claims as the billing provider. All owners must be identified and fully disclosed in the application; and

(((h))) (i) Have screened employees and contractors with whom they do business prior to hiring or contracting to assure that employees and contractors are not excluded from receiving federal funds as required by 42 U.S.C. 1320a-7 and 42.U.S.C. 1320c-5.

[11-14-075, recodified as 182-502-0010, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. 11-11-017, 388-502-0010, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.09.521. 08-12-030, 388-502-0010, filed 5/29/08, effective 7/1/08. Statutory Authority: RCW 74.08.090, 74.09.080, 74.09.120. 03-14-106, 388-502-0010, filed 6/30/03, effective 7/31/03. Statutory Authority: RCW 74.08.090, 74.09.500, and 74.09.530. 01-07-076, 388-502-0010, filed 3/20/01, effective 4/20/01; 00-15-050, 388-502-0010, filed 7/17/00, effective 8/17/00.]

OTS-4690.2


AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-543-2000   DME and related supplies, prosthetics, orthotics, medical supplies and related services -- Eligible providers and provider requirements.   (1) The ((department)) medicaid agency pays qualified providers for durable medical equipment (DME) and related supplies, prosthetics, orthotics, medical supplies, repairs, and related services on a fee-for-service basis as follows:

(a) DME providers who are enrolled with medicare for DME and related repair services;

(b) Medical equipment dealers who are enrolled with medicare, pharmacies who are enrolled with medicare, and home health agencies under their national provider indicator (NPI) for medical supplies;

(c) Prosthetics and orthotics providers who are licensed by the Washington state department of health in prosthetics and orthotics. Medical equipment dealers and pharmacies that do not require state licensure to provide selected prosthetics and orthotics may be paid for those selected prosthetics and orthotics only as long as the medical equipment dealers and pharmacies meet the medicare enrollment requirement;

(d) Physicians who provide medical equipment and supplies in the office. The ((department)) agency may pay separately for medical supplies, subject to the provisions in the department's resource-based relative value scale fee schedule; and

(e) Out-of-state orthotics and prosthetics providers who meet their state regulations.

(2) Providers and suppliers of durable medical equipment (DME) and related supplies, prosthetics, orthotics, medical supplies and related items must:

(a) Meet the general provider requirements in chapter ((388-502)) 182-502 WAC;

(b) Have the proper business license and be certified, licensed and/or bonded if required, to perform the services billed to the department;

(c) Have a valid prescription;

(i) To be valid, a prescription must:

(A) Be written on the ((department's)) agency's Prescription Form (((DSHS)) 13-794). The ((department's)) agency's electronic forms are available on-line at: ((http://www.dshs.wa.gov/msa/forms/eforms.html;)) http://hrsa.dshs.wa.gov/mpforms.shtml;

(B) Be written by a physician, advanced registered nurse practitioner (ARNP), or physician's assistant certified (PAC);

(C) Be written, signed (including the prescriber's credentials), and dated by the prescriber on the same day and before delivery of the supply, equipment, or device. Prescriptions must not be back-dated;

(D) Be no older than one year from the date the prescriber signs the prescription; and

(E) State the specific item or service requested, diagnosis, estimated length of need (weeks, months, or years), and quantity.

(ii) For dual eligible medicare/medicaid clients when medicare is the primary payer and the department is being billed for the co-pay and/or deductible only, subsection (2)(a) of this section does not apply.

(d) Provide instructions for use of equipment;

(e) Furnish only new equipment to clients that includes full manufacturer and dealer warranties. See WAC ((388-543-2250(3))) 182-543-2250(3);

(f) Furnish documentation of proof of delivery, upon ((department)) agency request (see WAC ((388-543-2200)) 182-543-2200); and

(g) Bill the ((department)) agency using only the allowed procedure codes listed in published DME and related supplies, prosthetics and orthotics, medical supplies and related items ((billing instructions)) medicaid provider guides.

[11-14-075, recodified as 182-543-2000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. 11-14-052, 388-543-2000, filed 6/29/11, effective 8/1/11; 07-17-062, 388-543-2000, filed 8/13/07, effective 9/13/07. Statutory Authority: RCW 74.08.090, 74.09.530. 01-01-078, 388-543-2000, filed 12/13/00, effective 1/13/01.]

Washington State Code Reviser's Office