WSR 04-01-099

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed December 16, 2003, 2:41 p.m. ]


     Date Adopted: December 10, 2003.

     Purpose: Redesign of the patient requiring regulation (PRR) rule in order to improve client safety and reduce unnecessary expense.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-501-0135.

     Statutory Authority for Adoption: RCW 74.08.090, 74.04.055.

     Other Authority: 42 C.F.R. Subpart B 431.51, 431.54 (e) and (3), and 456.1.

      Adopted under notice filed as WSR 03-20-073 on September 29, 2003.

     Changes Other than Editing from Proposed to Adopted Version: The following changes were made in the rule as proposed (additions indicated by underlined text, deletions indicated by strikethrough text):

WAC 388-501-0135 (first sentence):

     "Patient requiring regulation review and restriction (PRR) is a medical assistance administration (MAA) health and safety program for clients needing help in the appropriate use of medical services."

WAC 388-501-0135 (6)(a):

     "The department will send a written notice to the client or his or her the client's authorized representative that:...."

WAC 388-501-0135 (6)(a)(ii):

     "Directs the client to respond to the department within twenty calendar days after receiving the written notice: ,and:."

WAC 388-501-0135 (6)(a)(ii)(A):

     "To provide information on the selected provider(s); or...."

WAC 388-501-0135 (8)(b):

     "A client who requests a fair hearing within twenty calendar days from the date they the client receives notice under subsection (6)(a) of this section, will not be assigned to the PRR program until a fair hearing decision is made or if the client appeals, until a final order is issued."

WAC 388-501-0135 (8)(c):

     "A client who requests a fair hearing after twenty calendar days from the date he or she the client receives notice under subsection (6)(a) of this section, and who has already been assigned a provider or providers, will remain in PRR until a fair hearing decision is made and a final administrative order is issued."

WAC 388-501-0135 (10)(a):

     "The client moves to a residence outside the provider's geographic area; or ...."

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 1, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.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 0, 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.

December 10, 2003

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3320.4
AMENDATORY SECTION(Amending WSR 01-02-076, filed 12/29/00, effective 1/29/01)

WAC 388-501-0135   Patient ((requiring regulation)) review and restriction (PRR).   (((1))) Patient ((requiring regulation)) review and restriction (PRR) is a medical assistance administration (MAA) health and safety program for clients needing help in the appropriate use of medical services. ((A client in)) PRR is ((restricted to one primary care provider (PCP) and one pharmacy. Enrollment in the PRR program is for twenty-four months.

     (2) Any client of the department's medical programs is reviewed for assignment to PRR if:

     (a) The client has:

     (i) Made repeated and documented efforts to seek medically unnecessary health services; and

     (ii) Been counseled at least once by a health care provider or managed care plan representative about the appropriate use of health care services; or

     (b) Any three of the following conditions have been met or exceeded in a ninety-day period. The client:

     (i) Received services from four different physicians; or

     (ii) Had prescriptions filled by four different pharmacies; or

     (iii) Received ten prescriptions; or

     (iv) Had prescriptions filled by four different prescribers; or

     (v) Used two emergency room (ER) visits.

     (3) If subsections (2)(a) or (b) of this section apply, then the client's use of medical services is reviewed by the department. The review considers the client's diagnoses, history of services provided, or other medical information supplied by the health care provider or managed care plan. The review is done by a nurse consultant, physician, or other qualified medical staff according to established medical review guidelines.

     (4) If the medical review finds that the client uses inappropriate or medically unnecessary services the client receives written notice which:

     (a) Asks the client to select a primary care provider and one pharmacy; and

     (b) Notifies the client of their right to request a fair hearing within ninety days (see subsection (6) of this section); and

     (c) Requires the client to respond within twenty days by:

     (i) Selecting a primary care provider and pharmacy; or

     (ii) Submitting additional medical information, which justifies the client's use of medical services; or

     (iii) Writing or calling the PRR representative, who is identified in the PRR notice, requesting assistance; or

     (iv) Requesting a fair hearing (see subsection (6) of this section).

     (5) A client who does not respond to the notice within twenty days is assigned to the PRR program. The department assigns the client to a PCP and pharmacy. The client may change the assigned PCP and pharmacy once within the initial sixty days. The assigned providers will be:

     (a) Located in the client's local geographic area; and

     (b) Reasonably accessible to the client.

     (6) A client has ninety days to request a fair hearing. A client who requests a fair hearing within twenty days from the date they receive notice under subsection (4) of this section will not be assigned to the PRR program until a fair hearing decision is made. A client who requests a fair hearing after twenty days may have been assigned a PCP and pharmacist. An assigned client will remain in PRR until a fair hearing decision is made.

     (7) When a PRR client chooses or the department assigns a PCP and pharmacy, the PCP and pharmacy requirements are:

     (a) A PCP supervises and coordinates medical care for the client. The PCP makes referrals for specialist care and provides continuity of care. A PCP must be:

     (i) A physician who meets the criteria under WAC 388-502-0020 and 388-502-0030; or

     (ii) An advanced registered nurse practitioner (ARNP) who meets criteria under WAC 388-502-0020 and 388-502-0030; or

     (iii) A licensed physician assistant, practicing with a sponsoring supervising physician.

     (b) A single pharmacy fills all prescriptions for the client. For fee for service clients the pharmacy must be contracted with MAA.

     (c) For clients enrolled in a managed care plan, the pharmacy and PCP must be contracted with the client's managed care plan.

     (8) The PRR client's medical assistance identification card (MAID) will be marked in the "restricted" column.

     (9) A client in PRR cannot change their PCP or pharmacy for twelve months unless the:

     (a) Client changes to a residence outside the provider's geographic area; or

     (b) PCP or pharmacy moves out of the client's geographical area; or

     (c) PCP or pharmacy refuses to continue as the client's provider; or

     (d) Client was assigned providers. The client may change the assigned providers once within sixty days of the initial assignment.

     (10) A PRR client enrolled in a managed care plan must select a PCP and pharmacy from those identified as available within their plan. In addition to the reasons given in subsection (9) of this section, the client may change a provider if the:

     (a) Chosen or assigned PCP or pharmacy no longer participates with their plan. The client may:

     (i) Select a new PCP from the list of available PCPs provided by the plan; or

     (ii) Transfer enrollment of all family members to the new department-contracted plan which the established PCP has joined.

     (b) Client chooses a new plan during the managed care program's open enrollment period, which occurs during the twenty-four-month PRR enrollment period as defined in subsection (1) of this section.

     (11) After twenty-four months, a PRR client's use of services is reviewed. A client is removed from PRR if:

     (a) The billing records show the care received was reasonable and appropriate; or

     (b) The PCP reports the services requested and received were reasonable and appropriate.

     (12) If the client is not removed from PRR under subsection (11) of this section, the client continues to be in PRR for an additional twelve months. After that twelve-period, the client is reviewed again according to subsection (11)(a) and (b) of this section.

     (13) Under the PRR program, MAA or the client's managed care plan will pay for only:

     (a) Those services authorized by the PCP, the PCP-referred specialist, or the pharmacist; or

     (b) Emergencies services; or

     (c) Family planning services; or

     (d) Women's health care services. A client enrolled with a managed care plan must self-refer to providers within the plan's network.

     The client may be responsible for payment of services not covered by the PRR program)) authorized under federal Medicaid law by 42 USC 1396n (a)(2) and 42 CFR 431.54. A client is assigned to the PRR program based upon a determination by MAA of overuse or inappropriate use of medical services.

     (1) Definitions -- The following definitions apply to this section only:

     "Assigned provider"- A medical provider assigned by MAA staff in the PRR program to be the primary provider and coordinator of services for a client in the PRR program. A PRR client may have an assigned medical provider; an assigned pharmacy and an assigned hospital and may be restricted to these provider(s).

     "At-risk" means a medical history that includes evidence of life-threatening or potentially life-threatening events or conditions which required medical intervention.

     "Inappropriate use" - means use of medical services which are not adapted to or appropriate for a patient's medical needs.

     "Medically unnecessary" - means services that are nonessential, redundant, and/or not necessary for a patient's medical care.

     "Overuse" - means the excessive use of medical services well beyond the patient's medically necessary care.

     (2) Clients selected for review -- Clients are selected for PRR review by:

     (a) An "exception report" produced by the Medicaid Management Information System; or

     (b) Direct referral from medical providers, social service agencies or other concerned parties.

     (3) Initial review criteria -- Any client of the department's medical programs may be considered for assignment to PRR if conditions in either (a) or (b) of this subsection apply:

     (a) Any two or more of the following conditions have been met in a period of ninety calendar days in the previous twelve months. The client:

     (i) Received services from four or more different physicians;

     (ii) Had prescriptions filled by four or more different pharmacies;

     (iii) Received ten or more prescriptions;

     (iv) Had prescriptions written by four or more different prescribers; or

     (v) Received similar services from two or more providers in the same day.

     (b) Any one of the following conditions applies: The client has:

     (i) Made two or more emergency department visits in a ninety-day period;

     (ii) A medical history indicating at-risk utilization patterns; or

     (iii) Made repeated and documented efforts to seek medically unnecessary services and been counseled at least once by a health care provider or managed care representative about the appropriate use of health care services.

     (4) Request for clinical review -- If either subsection (2)(a) or (b) of this section applies, PRR program staff may review the client's medical and billing history for overuse or inappropriate use of medical services and on a case-by-case basis decide to:

     (a) Close the file;

     (b) Send the client a letter of concern with information on specific findings and notice of potential placement in the PRR program; or

     (c) Request a clinical review of the records.

     (5) Clinical review -- A nurse consultant, physician, or other qualified clinical staff at MAA may review the client's medical records to determine if there is a history of overuse or inappropriate or medically unnecessary use of services. The reviewer relies on established medical guidelines and may on a case-by-case basis decide to:

     (a) Take no action and close the PRR file; or

     (b) Proceed with any or all of the following:

     (i) Continue to monitor the client's utilization pattern for thirty to sixty days;

     (ii) Refer the client for education on appropriate use of services;

     (iii) Refer the client to other support services or agencies; or

     (iv) Assign the client to the PRR program.

     (6) Client restriction -- When the clinical review determines that the client has obtained inappropriate or medically unnecessary services, by established medical guidelines, the client will be restricted:

     (a) The department will send a written notice to the client or the client's authorized representative that:

     (i) Asks the client to select a primary care provider (PCP) and/or a pharmacy and/or a hospital. (See WAC 388-546-5000 through 388-546-5400 for limitations on nonemergency transportation services.)

     (ii) Directs the client to respond to the department within twenty calendar days after receiving the written notice:

     (A) To provide information on the selected provider(s);

     (B) To submit additional medical information, justifying the client's use of medical services; or

     (C) To request assistance from PRR program staff.

     (iii) Informs the client of fair hearing rights (see subsection (8) of this section); and

     (iv) Informs the client that, if a response is not received within twenty calendar days, the client will be restricted to provider(s) assigned by the PRR program.

     (b) After twenty calendar days, the PRR program may restrict the client to the specific provider(s) either chosen by the client or assigned by the program.

     (7) Assigned providers -- Assigned providers will be:

     (a) Located in the client's local geographic area; and/or

     (b) Reasonably accessible to the client.

     (8) Fair hearing rights

     (a) A client has ninety calendar days following the date of the department's notice in which to request a fair hearing.

     (b) A client who requests a fair hearing within twenty calendar days from the date the client receives notice under subsection (6)(a) of this section, will not be assigned to the PRR program until a fair hearing decision is made or if the client appeals, until a final order is issued.

     (c) A client who requests a fair hearing after twenty calendar days from the date the client receives notice under subsection (6)(a) of this section, and who has already been assigned a provider or providers, will remain in PRR until a fair hearing decision is made and a final administrative order is issued. (The client will remain in PRR if the fair hearing decision is adverse to the client.)

     (9) Provider selection and role -- For fee for service clients the providers must be contracted with MAA.

     (a) The selected primary care provider (PCP) must be either:

     (i) A physician who meets the criteria under WAC 388-502-0020 and 388-502-0030;

     (ii) An advanced registered nurse practitioner (ARNP) who meets criteria under WAC 388-502-0020 and 388-502-0030; or

     (iii) A licensed physician assistant, practicing with a sponsoring supervising physician.

     (b) The PCP supervises and coordinates medical care for the client on restriction. The PCP provides continuity of care and refers to specialists when necessary.

     (c) A single pharmacy fills all prescriptions for the client.

     (d) A single hospital provides all nonemergent and outpatient hospital care for the client.

     (10) Provider changes -- A client in PRR cannot change the assigned providers for twelve months after the assignments are made, unless:

     (a) The client moves to a residence outside the provider's geographic area;

     (b) The provider moves out of the client's geographical area;

     (c) The provider refuses to continue to serve the client; or

     (d) The client did not select the provider. The client may change a department-assigned provider once within sixty calendar days of the initial assignment.

     (11) Managed care clients on PRR -- A client in PRR enrolled in an MAA managed care plan must select a primary care provider (PCP) and/or a pharmacy and/or a hospital from those identified as available within the plan. In addition to the reasons given in subsection (9) of this section, the client may change a provider if the chosen or assigned PCP or pharmacy no longer participates with the plan. In such a situation, the client may:

     (a) Select a new PCP from the list of available PCPs provided by the plan; or

     (b) Transfer enrollment of all family members to the new department-contracted plan that the established PCP has joined.

     (12) Lifting or continuing restrictions After twenty-four months of assignment to the PRR program, a PRR client's use of services is reviewed.

     (a) A client is removed from PRR after the twenty-four-month review if:

     (i) Clinical and billing documentation show the client's care was reasonable and appropriate; and/or

     (ii) The PCP reports the services requested and received were reasonable and appropriate.

     (b) If the client is not removed from PRR after the twenty-four-month review, the client remains in PRR for an additional twelve months. After that twelve-month period, the client is reviewed again pursuant to this subsection.

     (13) Client financial responsibility -- So long as the requirements of WAC 388-502-0160 are followed, a client who is restricted under the PRR program may be billed for services and held financially responsible for:

     (a) Services that MAA and/or the client's health plan determine are not medically necessary; and:

     (b) Nonemergent services obtained from providers or facilities other than those assigned under the PRR program.

[Statutory Authority: RCW 74.08.090. 01-02-076, § 388-501-0135, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090. 98-16-044, § 388-501-0135, filed 7/31/98, effective 9/1/98. Statutory Authority: RCW 74.08.090 and 74.09.522. 97-03-038, § 388-501-0135, filed 1/9/97, effective 2/9/97. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-501-0135, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-100.]