PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Purpose: (Part 2 of 2) The rule updates the department's policy for reimbursement for outpatient hospital services in order to be consistent with the filing of a new rule to implement the OPPS program. In addition, the department is no longer using the twenty-four-hours-or-less criteria in the definition for "outpatient short stay" and is replacing language related to the twenty-four-hours-or-less criteria in WAC 388-550-6000 with alternate language.
Citation of Existing Rules Affected by this Order: Amending WAC 388-550-6000.
Statutory Authority for Adoption: RCW 74.08.090 and 74.09.500.
Adopted under notice filed as WSR 04-17-110 on August 17, 2004.
A final cost-benefit analysis is available by contacting Cynthia Smith, P.O. Box 45510, Olympia, WA 98504, phone (360) 725-1830, fax (360) 753-9152, e-mail smithch@dshs.wa.gov. The cost-benefit analysis (CBA) is unchanged from the preliminary version.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.
Date Adopted: September 27, 2004.
Brian H. Lindgren, Manager
Rules and Policies Assistance Unit
3445.1(1) Maximum allowable fee schedule:
(a) MAA uses the maximum allowable fee schedule to pay for services listed in the outpatient hospital fee schedule and published in MAA's billing instructions.
(b) Outpatient hospital services are included in the outpatient hospital fee schedule when:
(i) A technical component has been established in the Medicare Fee Schedule Data Base (MFSDB); or
(ii) MAA specifically identifies certain services for payment using the maximum allowable fee schedule.
(c) Outpatient hospital services paid using MAA's maximum allowable fee schedule include:
(i) Laboratory services;
(ii) Imaging services;
(iii) EKG/ECG/EEG and other diagnostics;
(iv) Physical therapy;
(v) Occupational therapy;
(vi) Speech/language therapy;
(vii) Synagis;
(viii) Sleep studies; and
(ix) Other hospital services as identified and published by the department.
(d) MAA's payment for covered services included in the outpatient hospital fee schedule is the lesser of:
(i) The hospital's billed amount; or
(ii) MAA's maximum allowable.
(e) Certain services or supplies listed in the outpatient hospital fee schedule are identified and designated by MAA to be paid by acquisition cost or by report. See subsection (7) of this section for MAA's requirement for submitting invoices.
(2) Outpatient rate:
(a) MAA uses the outpatient rate to pay hospitals for covered services reported on a hospital claim that are not listed in the outpatient hospital fee schedule.
(b) The outpatient rate is a hospital-specific rate that uses the hospital's ratio of costs-to-charges (RCC) rate as its base. MAA's rate-setting method for an outpatient rate is described in WAC 388-500-4500.
(3) The department considers hospital stays of twenty-four hours or less outpatient short stays and uses the outpatient payment methods in subsections (1) and (2) of this section to pay a hospital for these services. However, when an outpatient short stay involves one of the following situations, the department uses inpatient payment methods to pay a hospital for covered services:
(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.
(4) The department uses the outpatient payment methods in subsections (1) and (2) of this section to pay for covered inpatient hospital services provided within twenty-four hours of a client's inpatient admission that are not related to the admission. Inpatient hospital services provided within twenty-four hours of a client's inpatient admission that are related to the admission are paid according to WAC 388-550-2900(12).
(5) For a client enrolled in an MAA-contracted managed care plan, the plan is responsible to pay a hospital provider for hospital services that the plan covers. MAA pays for a service not covered by the managed care plan only when:
(a) The service is included in the scope of coverage under the client's medical assistance program;
(b) The service is medically necessary as defined in WAC 388-550-1050; and
(c) The provider has a current core provider agreement with MAA and meets applicable MAA program requirements in other published WACs.
(6) The department does not pay for:
(a) Room and ancillary services charges beyond the twenty-four hour period for outpatient short stays; or
(b) Emergency room, labor room, observation room, and other room charges in combination when billing periods for theses charges overlap.
(7) In order to be paid for covered outpatient hospital services listed in the outpatient hospital fee schedule as a paid at acquisition cost or by report, MAA requires the hospital provider to submit an invoice for billed amounts of five hundred or more.
(8) In order to be paid for covered outpatient hospital services, hospitals must bill MAA according to the conditions of payment under WAC 388-502-0100, time limits under WAC 388-502-0150, and other applicable published issuances. In addition, MAA requires hospitals to bill outpatient claims using the line item date of service and the appropriate revenue codes, admit and discharge hour, current procedural terminology (CPT) codes, healthcare common procedural coding system (HCPSCS) codes, and modifiers listed in MAA's published outpatient hospital fee schedule. A hospital's bill to the department must show the admitting, principal, and secondary diagnoses and include the attending physician's name and MAA-assigned provider number)) hospitals for covered outpatient hospital services provided to eligible clients when the services meet the provisions in WAC 388-550-1700. All professional medical services must be billed according to chapter 388-531 WAC.
(2) To be paid for covered outpatient hospital services, a hospital provider must:
(a) Have a current core provider agreement with MAA;
(b) Bill MAA according to the conditions of payment under WAC 388-502-0100;
(c) Bill MAA according to the time limits under WAC 388-502-0150; and
(d) Meet program requirements in other applicable WAC and MAA published issuances.
(3) MAA does not pay separately for any services:
(a) Included in a hospital's room charges;
(b) Included as covered under MAA's definition of room and board (e.g., nursing services). See WAC 388-550-1050; or
(c) Related to an inpatient hospital admission and provided within one calendar day of a client's inpatient admission.
(4) MAA does not pay:
(a) A hospital for outpatient hospital services when a managed care plan is contracted with MAA to cover these services;
(b) More than the "acquisition cost" ("A.C.") for HCPCS (Healthcare Common Procedure Coding System) codes noted in the outpatient fee schedule as paid "A.C."; or
(c) For cast room, emergency room, labor room, observation room, treatment room, and other room charges in combination when billing periods for these charges overlap.
(5) MAA uses the outpatient departmental weighted costs-to-charges (ODWCC) rate to pay for covered outpatient services provided in a critical access hospital (CAH). See WAC 388-550-2598.
(6) MAA uses the maximum allowable fee schedule to pay non-OPPS hospitals and non-CAH hospitals for the following types of covered outpatient hospital services listed in MAA's current published outpatient hospital fee schedule and billing instructions:
(a) Laboratory services;
(b) Imaging services;
(c) EKG/ECG/EEG and other diagnostics;
(d) Physical therapy;
(e) Speech/language therapy;
(f) Synagis;
(g) Sleep studies; and
(h) Other hospital services identified and published by the department.
(7) MAA uses the hospital outpatient rate as described in WAC 388-550-4500 to pay for covered outpatient hospital services when:
(a) A hospital provider is a non-OPPS or a non-CAH provider; and
(b) The services are not included in subsection (6) of this section.
(8) Hospitals must provide documentation as required and/or requested by MAA.
[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. 03-19-044, § 388-550-6000, filed 9/10/03, effective 10/11/03. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. 02-21-019, § 388-550-6000, filed 10/8/02, effective 11/8/02. Statutory Authority: RCW 74.09.090, 42 U.S.C. 1395x(v), 42 C.F.R. 447.271 and 42 C.F.R. 11303. 99-14-028, § 388-550-6000, filed 6/28/99, effective 7/1/99. 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.]