PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Date of Adoption: June 1, 2001.
Purpose: WAC 388-501-0050 Medical and dental general coverage, to explain the criteria for determining if services, equipment, and supplies are covered by the Medical Assistance Administration.
Citation of Existing Rules Affected by this Order: Amending WAC 388-501-0050.
Statutory Authority for Adoption: RCW 74.08.090.
Adopted under notice filed as WSR 00-23-051 on November 13, 2000.
Changes Other than Editing from Proposed to Adopted Version: The following changes to the rule text, illustrated by strikeout and underline, were made since the rule was proposed on November 13, 2000:
(1) Covered Services
(a) Covered services are:
(i) Medical and dental services, equipment, and supplies
that are within the scope of the eligible client's medical
assistance program (see chapter 388-529 WAC) and listed as
covered in MAA rules, billing instructions, or numbered
memoranda; and
(ii) Determined by MAA to be medically necessary as defined
in WAC 388-500-0005 or dentally necessary as defined in WAC 388-535-0150.
(b) Providers must obtain prior authorization (PA) or
expedited prior authorization (EPA) when required by WAC, billing
instructions, or numbered memoranda MAA
(i) See WAC 388-501-0165 for the prior authorization (PA)
process.
(ii) The EPA process is designed to eliminate the need for
written and telephonic requests for prior authorization for
selected services and procedure codes. MAA requires a provider
to create an authorization number for EPA for selected procedure
codes, using the process explained in the billing instructions
for the specific service or program See MAA billing instructions
for specific criteria for the expedited prior authorization (EPA)
process.
(iii) See chapter 388-538 WAC for managed care requirements.
(c) Covered services are subject to the limitations
specified by WAC, billing instructions, or numbered memoranda
MAA. Providers must obtain prior authorization PA or expedited
prior authorizationv EPA before providing services that exceed
the specified limit (quantity, frequency or duration). This is
known as a limitation extension.
(i) See WAC 388-501-0165 for specific criteria for the prior
authorization (PA) process.
(ii) The EPA process is designed to eliminate the need for
written and telephonic requests for prior authorization for
selected services and procedure codes. MAA requires a provider
to create an authorization number for EPA for selected procedure
codes, using the process explained in the billing instructions
for the specific service or program See MAA billing instructions
for the expedited prior authorization (EPA) process.
(iii) See chapter 388-538 WAC for managed care requirements.
(d) MAA does not reimburse for covered services, equipment
or supplies that are:
(i) That are Iincluded in a DSHS waivered program, e.g.,
COPES; or
(ii) For an MAA client who is Medicare-eligible, if:
(A) The services, equipment or supplies are covered under Medicare; and
(ii)(iii) Medicare has not made a determination on the claim
or has not been billed by the provider Part of one of the
Medicare programs for qualified Medicare beneficiaries.
(2) Noncovered Services
(a) MAA does not cover services, equipment or supplies to which any of the following apply:
(i) The service or equipment is not included as a covered service in the state plan;
(ii) Federal or state laws or regulations prohibit coverage;
(iii) The service or equipment is considered experimental or investigational by the Food and Drug Administration or the Health Care Financing Administration; or
(iv) MAA rules, billing instructions, or numbered memoranda
do not list the service or equipment as covered.
(b) If a noncovered service, equipment or supply is required
under the EPSDT/Healthy Kids program, it will be reviewed for
medical necessity as a covered service. MAA reviews all initial
requests for noncovered services based on WAC 388-501-0165.
(c) MAA reviews all initial requests for noncovered services
based on WAC 388-501-0165. If a noncovered service, equipment or
supply is prescribed under the EPSDT program, it will be
evaluated as a covered service and reviewed for medical
necessity.
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.
Effective Date of Rule:
Thirty-one days after filing.
June 1, 2001
Brian H. Lindgren, Manager
Rules and Policies Assistance Unit
2876.4(1) Covered Services
(a) Covered services are:
(i) Medical and dental services, equipment, and supplies that are within the scope of the eligible client's medical assistance program (see chapter 388-529 WAC) and listed as covered in MAA rules; and
(ii) Determined to be medically necessary as defined in WAC 388-500-0005 or dentally necessary as defined in WAC 388-535-0150.
(b) Providers must obtain prior authorization (PA) or expedited prior authorization (EPA) when required by MAA.
(i) See WAC 388-501-0165 for the PA process.
(ii) The EPA process is designed to eliminate the need for written and telephonic requests for prior authorization for selected services and procedure codes. MAA requires a provider to create an authorization number for EPA for selected procedure codes, using the process explained in the billing instructions for the specific service or program.
(iii) See chapter 388-538 WAC for managed care requirements.
(c) Covered services are subject to the limitations specified by MAA. Providers must obtain PA or EPA before providing services that exceed the specified limit (quantity, frequency or duration). This is known as a limitation extension.
(i) See WAC 388-501-0165 for the PA process.
(ii) The EPA process is designed to eliminate the need for written and telephonic requests for prior authorization for selected services and procedure codes. MAA requires a provider to create an authorization number for EPA for selected procedure codes, using the process explained in the billing instructions for the specific service or program.
(iii) See chapter 388-538 WAC for managed care requirements.
(d) MAA does not reimburse for covered services, equipment or supplies:
(i) That are included in a DSHS waivered program; or
(ii) For a MAA client who is Medicare-eligible if:
(A) The services, equipment or supplies are covered under Medicare; and
(B) Medicare has not made a determination on the claim or has not been billed by the provider.
(2) Noncovered services
(a) MAA does not cover services, equipment or supplies to which any of the following apply:
(i) The service or equipment is not included as a covered service in the state plan;
(ii) Federal or state laws or regulations prohibit coverage;
(iii) The service or equipment is considered experimental or investigational by the Food and Drug Administration or the Health Care Financing Administration; or
(iv) MAA rules do not list the service or equipment as covered.
(b) MAA reviews all initial requests for noncovered services based on WAC 388-501-0165.
(c) If a noncovered service, equipment or supply is prescribed under the EPSDT program, it will be evaluated as a covered service and reviewed for medical necessity.
[Statutory Authority: RCW 74.04.050 and 74.08.090. 00-01-088, 388-501-0050, filed 12/14/99, effective 1/14/00.]