Date of Adoption: June 28, 1999.

Purpose: To clarify department policy without changing policy. To comply with the Governor's Executive Order 97-02 which mandates that rules be reviewed for clarity, foundation in law, etc.

Citation of Existing Rules Affected by this Order: Amending WAC 388-550-6000 Payment--Outpatient hospital services.

Statutory Authority for Adoption: RCW 74.09.090, 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, 42 C.F.R. 11303.

Adopted under notice filed as WSR 99-09-089 on April 21, 1999.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 1, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.

Other Findings Required by Other Provisions of Law as Precondition to Adoption or Effectiveness of Rule: Per RCW 34.05.380(3), the rule must become effective July 1, 1999, because the senate budget bill (ESSB 5180) and the budget notes defining the budget bill mandate this effective date.Effective Date of Rule: July 1, 1999.

June 28, 1999

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

(1)(a) Excluding nonallowable revenue codes and the services specified in subsection (2) below MAA determines allowable costs for hospital outpatient services((, excluding nonallowable revenue codes,)) by the application of the hospital-specific outpatient ratio of costs to charges (RCC)((, except as specified in subsection (2) below)).

(b) MAA does not pay separately for ancillary hospital services which are included in the hospital's RCC reimbursement rate.

(2) MAA pays the lesser of billed charges or MAA’s published maximum allowable fees for the following outpatient services:

(a) Laboratory/pathology;

(b) Radiology, diagnostic and therapeutic;

(c) Nuclear medicine;

(d) Computerized tomography scans, magnetic resonance imaging, and other imaging services;

(e) Physical therapy;

(f) Occupational therapy;

(g) Speech/language therapy; and

(h) Other hospital services as identified and published by the department.

(3) MAA is not responsible for payment of hospital care and/or services provided to a client enrolled in a MAA-contracted, prepaid medical plan when the client fails to use:

(a) For a nonemergent condition, a hospital provider under contract with the plan;

(b) In a bona fide emergent situation, a hospital provider under contract with the plan; or

(c) The provider whom MAA has authorized to provide and receive payment for a service not covered by the prepaid plan, but covered under the client's medical assistance program.

(4) Providers or managed care entities that charge Medicare beneficiaries excess amounts are subject to sanctions as listed in 42 U.S.C. 1320A-7b(d)(1). These sanctions include a fine of up to twenty-five thousand dollars or imprisonment of up to five years, or both.

(5) MAA considers a hospital stay of twenty-four hours or less as an outpatient short stay.   MAA does not pay an outpatient short stay under the ((diagnosis-related group)) DRG system except when it involves one of the following situations:

(a) Death of a client;

(b) Obstetrical delivery;

(c) Initial care of a newborn; or

(d) Transfer of a client to another acute care hospital.

(((5))) (6) MAA does not pay for patient room and ancillary services charges beyond the twenty-four period for outpatient stays.

(((6))) (7) MAA does not cover short stay unit, emergency room facility ((charges)), and labor room charges in combination when ((the billed)) these billing periods overlap.

(((7))) (8) MAA requires that the hospital's bill to the department shows the admitting, principal, and secondary diagnoses((, and)). Include the attending physician's name and MAA provider number.

(((8))) (9) Payments for trauma services may be enhanced per WAC 246-976-935.

[Statutory Authority: RCW 74.08.090, 42 USC 1395 x(v), 42 CFR 447.271, 447.11303, and 447.2652.  99-06-046, § 388-550-6000, filed 2/26/99, effective 3/29/99.  Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020.  98-01-124, § 388-550-6000, filed 12/18/97, effective 1/18/98.]

Reviser's note: The bracketed material preceding the section above was supplied by the code reviser's office.

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