SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Date of Adoption: December 6, 2000.
Purpose: The department is establishing a new chapter for rules pertaining to physician-related services, and in order to avoid duplication, is repealing existing rules on the same subject. The new rules meet the clear-writing mandates in the Governor's Executive Order 97-02, and ensure that current policy and practice are reflected in rule, new chapter 388-531 WAC.
Citation of Existing Rules Affected by this Order: Repealing WAC 388-86-011, 388-86-055, 388-86-095, 388-86-110, 388-86-0961, 388-87-075, and 388-87-095.
Statutory Authority for Adoption: RCW 74.08.090, 74.09.520.
Adopted under notice filed as WSR 00-12-080 on June 6, 2000.
Changes Other than Editing from Proposed to Adopted Version: (Deleted words shown as
strikeout and added words shown as
"Allowed charges" means the maximum amount reimbursed for any procedure that is allowed by MAA.
"Covered service" means a service that is within the scope
of the eligible client's medical care program,
and listed in
specific fee-for-service billing instructions. subject to the
limitations in this chapter and other published WAC.
"Experimental" means... (2) Has been approved by the FDA or other requisite government body, if such approval is required.
"Fee-for-service" means the general payment method MAA uses
to reimburse providers for covered medical services provided to
medical assistance clients
for whom when those services are not
covered under MAA's healthy options program or children's health
insurance (CHIP) programs.
"Investigational" means a term to describe a procedure, or course of treatment, which lacks sufficient scientific evidence of benefit for a particular condition. A service is not "investigational" if the service:...
(2) Is supported by
a preponderance an overall balance of
objective scientific evidence, in which the potential risks and
potential benefits are examined...
(2) MAA evaluates a request for any service that is listed
as noncovered in WAC 388-531-0150 under the provisions of WAC 388-501-0165
which relate to noncovered services.
(5) MAA covers the following physician-related services,
subject to the conditions in subsection (1),
and (2) (3), and (4)
of this section:...
Ophthalmology care Vision-related services per
chapter 388-544 WAC;
Orthoptic eye training therapy; Vision-related
services listed as non-covered in chapter 388-544 WAC;
WAC 388-531-0250 (1)(k):
, for vision-related optometric services; or
, for podiatric services.
WAC 388-531-0450 (2)(a): The client is critically ill and
the physician is engaged in work directly related to the
individual clients care, whether that time is spent at the
beside bedside, or elsewhere on the floor;
In making The determination of whether a service is
experimental and/or investigational and therefore, not a covered
service, MAA considers the following: is subject to a
case-by-case review under the provisions of WAC 388-501-0165
which relate to medical necessity. MAA also considers the
(2)(b) Whether evidence indicates the service or treatment is more likely than not to be as beneficial as existing conventional treatment alternatives for the treatment of the condition in question;
(c) Any relevant, specific aspects of the condition; (the
subsections following this, ((d), (e), (f), (g), (h), and (i))
are renumbered, respectively, as (c), (d), (e), (f), (g), and
(d) (c) Whether the service or treatment is generally
used or generally accepted for treatment of for the condition in
the state of Washington United States.
(3) MAA applies consistently across clients with the same
medical condition and health status, the criteria to determine
whether a service is experimental. A service that is not
experimental for one client with a particular medical condition
is not determined to be experimental for another enrollee with
the same medical condition and
similar health status. A service
that is experimental for one client with a particular medical
condition is not necessarily experimental for another, and
subsequent individual determinations must consider any new or
additional evidence not considered in prior determinations.
(4) MAA does not determine a service or treatment to be
experimental or investigational solely because it is under
clinical investigation, when there is sufficient evidence in
peer-reviewed medical literature to draw conclusions, and the
evidence indicates the service or treatment will probably be of
greater overall benefit to the client in question
and to others
similarly situated, than another generally available service.
inpatient physician-related services.
(1) MAA reimburses a provider
s for laboratory services only
when they are:
(a) The provider is
Are certified according to Title XVII of
the Social Security Act (Medicare), if required; and
(a) The provider has
Have a clinical laboratory improvement
amendment (CLIA) certificate and identification number.
(11) An independent laboratory must bill MAA directly. MAA does not reimburse a medical practitioner for services referred to or performed by an independent laboratory.
(1)(a) Two calls per month for routine medical conditions for a client residing in a nursing facility;
(1)(b) One call per noninstitutionalized client, per day,
per for an individual physician....
(5)(b) The injectable drug used is from office stock and purchased by the provider from...
(9)(a) MAA does not pay separately
reimburse for the
administration of intra-arterial and intravenous therapeutic or
diagnostic injections provided in conjunction with intravenous
infusion therapy services. MAA does pay reimburse separately for
the administration of these injections when they are provided on
the same day as an E&M service. MAA does not pay separately an
administration fee for injectables when both E&M and infusion
therapy services are provided on the same day. MAA reimburses
separately for the drug(s).
(9)(b) MAA does not
reimburse pay separately for
subcutaneous or intramuscular administration of antibiotic
injections provided on the same day as an E&M service. If the
injection is the only service provided, MAA covere the injection
service pays an administration fee. ...
(9)(d) The provider must submit a manufacturer's invoice
to document the name, strength, and dosage on the claim form when
billing MAA for the following drugs:
(i) Classified drugs
that cost where the billed charge is
over one thousand, one hundred dollars; and
(i) Unclassified drugs
that cost where the billed charge is
over one hundred dollars ; and This does not apply to unclassified
antineoplastic drugs. (i) Unclassified antineoplastic drugs that cost over five
(10)(b) When a single client is expected to use all the
doses in a multiple dose vial, the provider
must may bill MAA the
total number of doses in a multiple dose vial the vial at the
time the first dose from the vial is used. (c) When remaining
doses of a the multiple dose vial are injected at subsequent
times, MAA reimburses the injection service (administration fee)
(c) When a multiple dose vial is used for more than one client, the provider must bill the total number of doses provided to each client out of the multiple dose vial.
(d) MAA covers
both the injection and the antigen, the
antigen preparation, and an administration fee.
(11) MAA reimburses for chemotherapy drugs:
MAA reimburses for chemotherapy drugs Administered
in the physician's office only when:...
MAA establishes a At established maximum allowable
fees based on its the Medicare pricing of the estimated
acquisition cost (EAC) or maximum allowable cost (MAC), when
generics are available;.
(11)(c) For unclassified antineoplastic drugs, the provider must submit the following information on the claim form:
(i) The name of the drug used;
(i) The dosage and strength used; and
(i) The national drug code (NCD).
(12) Notwithstanding the provisions of this section, MAA reserves the option of determining drug pricing for any particular drug based on the best evidence available to MAA, or other good and sufficient reasons (e.g., fairness/equity, budget), regarding the actual cost, after discounts and promotions, paid to typical providers nationally or in Washington state.
(13) MAA may request an invoice as necessary.
Opthalmological Ophthalmic and vision-related
physician-related services. (1) MAA covers opthalmological services furnished by a
provider as listed in WAC 388-531-0250, and subject to the
limitations in this section and other published WAC.
(1) MAA requires expedited prior authorization for strabismus surgery for clinet eighteen years of age and older.
(1) MAA does not cover any of the following:
(a) Orthoptics and visual training therapy;
(b) Two pairs of eyeglasses;
(c) E&M services billed in combination with eye exam procedure codes;
(d) Radial Keratotomy or other surgery for refractive purposes;
(e) Refractive prescriptions over two years old; of
(f) Group screening for eyeglasses (except for EPSDT).
Refer to chapter 388-544 WAC for ophthalmic and vision-related services.
(1) MAA covers medical services provided to
eligible clients who are temporarily located outside the state,
subject to the provisions of this chapter and WAC 388-501-0180.
(5) MAA reimburses only one psychiatric diagnostic interview
examination in a calendar year unless a significant change in the
client's circumstances renders
such a an additional evaluation
(11) MAA reimburses hysterectomy without prior authorization in either of the following circumstances: (a) the client has been diagnosed with cancer(s) of the female reproductive organs; and/or (b) the client is forty-six years of age or older.
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 38, Amended 0, Repealed 7.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 38, Amended 0, Repealed 7.
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 38, Amended 0, Repealed 7. Effective Date of Rule: Thirty-one days after filing.
December 6, 2000
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit
Reviser's note: The material contained in this filing exceeded the page-count limitations of WAC 1-21-040 for appearance in this issue of the Register. It will appear in the 01-03 issue of the Register.