Effective Date of Rule: August 1, 2007.

     Purpose: The rules update and clarify information regarding the department's inpatient psychiatric services coverage (including adding applicable definitions), payment policy, and general policy for hospital care. The rules also clarify how the department pays a hospital for covered dental-related services that are provided in the hospital's operating room. Also, effective for dates of admission on and after July 1, 2007, the base community psychiatric hospitalization payment method for medicaid and state children's health insurance program (SCHIP) clients and non-medicaid and non-SCHIP clients is no longer used. (A "non-medicaid or non-SCHIP client" is defined as a client eligible under the general assistance-unemployable (GA-U) program, the Alcoholism and Drug Addiction Treatment and Support Act (ADATSA), the psychiatric indigent inpatient (PII) program, or other state-administered program, as determined by the department.)

     Citation of Existing Rules Affected by this Order: Amending WAC 388-550-1100, 388-550-2600, and 388-550-2650.

     Statutory Authority for Adoption: RCW 74.08.090, 74.09.500.

      Adopted under notice filed as WSR 07-10-093 on May 1, 2007.

     Changes Other than Editing from Proposed to Adopted Version: WAC 388-550-1100 (5)(b)(iv) as an inpatient stay is not indicated;

     WAC 388-550-2600 (2)(a)(i) Is assigned... administrative prior authorization...

     WAC 388-550-2600 (2)(b) "Certification" means a clinical determination by a an MHD... The certification process occurs concurrently with the administrative prior authorization process.

     WAC 388-550-2600 (2)(c) "I.D." "IMD" See...

     WAC 388-550-2600 (2)(d) "Institution for Mental Diseases (I.D.) (IMD)" means a... The MHD designates... for an I.D. IMD.

     WAC 388-550-2600 (2)(j) "Prior authorization" means an administrative process by which hospital provides providers must obtain a an MHD designee's certification authorization for a client's... The administrative prior authorization...

     WAC 388-550-2600 (2)(l) "Retrospective authorization" means a process... unit providers must obtain a an MHD designee's certification after services have been initiated for a medical assistance client. Retrospective authorization can be prior to discharge or after discharge. This process...prevented a prior authorization request, or when the client has been determined to be eligible for medical assistance after discharge.

     WAC 388-550-2600 (3)(c) Hospitals that provide active psychiatric treatment (according to WAC 246-322-0170) outside of a physician according to WAC 246-322-170.

     WAC 388-550-2600 (3)(d) Free-standing… as an institution for mental diseases (I.D.) (IMD).

     WAC 388-550-2600(4) An MHD designee has the authority to approve or deny a request for initial certification for a client's voluntary inpatient psychiatric admission and will respond to the hospital's or hospital unit's request for initial certification within two hours of the request. An MHD designee's certification and authorization, or a denial, will be provided within twelve hours of the request. Authorization must be requested prior to admission. If the hospital chooses to admit a client without prior authorization due to staff shortages, the request for an initial certification must be submitted the same calendar day (which begins at midnight) as the admission. In this case, the hospital assumes the risk for denial as the MHD designee may or may not authorize the care for that day.

     WAC 388-550-2600(4) (5)(b)(i)(C) Be prior... See subsection (7) (8) of this section... (D)(II) Proper treatment... of a physician (according to WAC 246-322-170);

     WAC 388-550-2600(4) (5)(b)(i)(D)(V) For admission to long term inpatient psychiatric care, the client has been diagnosed with a severe psychiatric disorder that warrants extended care in the most intensive, restrictive setting. The client's principle diagnosis must be an MHD covered diagnosis.

     WAC 388-550-2600(4) (5)(b)(i)(D)(V)(III)(A) Does not require prior authorization by a an MHD...

     WAC 388-550-2600(5) (6)(b)(iii) When submitting a claim, must include... copy of Involuntary treatment Act Patient Claim Information for (DSHS 13-628) an initial certification authorization for admission to inpatient psychiatric care form, or an extension certification authorization for continued inpatient psychiatric care form.

     WAC 388-550-2600(6) (7) To be paid... request from a an MHD designee...

     WAC 388-550-2600(6) (7)(a) If the client... must notify the MHD designee prior to the change of status within twenty-four hours of the change. Changes in legal status may result in issuance of a new certification and authorization. Any previously authorized days under the previous legal status that are past the date of the change in legal status are not billable. (b) If an application... must be submitted by the close of the next business day within twenty-four hours of the application; (c) If there is... diagnosis to a mental disorder an MHD covered diagnosis, the request for certification and prior authorization must be submitted within two business days twenty-four hours of the change; (d) If there is a request... to the end of the initial allowed authorized days of services...

     WAC 388-550-2600(6) (7)(d) If there is... end of the initial allowed authorized days of services (see subsections (10) and (11) and (12) of this section for payment...

     WAC 388-550-2600(6) (7)(f) If a client who has been authorized for inpatient care by the MHD designee has been discharged or left against medical advice prior to the expiration of previously authorized days, a hospital provider or hospital unit provider must notify the MHD designee within twenty-four hours of discharge. Any previously authorized days past the date the client was discharged or left the hospital are not billable.

     WAC 388-550-2600(7) (8) A An MHD designee... extension, or transfer that was not prior authorized when the hospital provider or hospital unit provider did not notify the MHD designee within the notification timeframes stated in this section. For a retrospective certification request prior to discharge, The the MHD designee responds to the hospital or hospital unit within three working days two hours of the request, and provides certification and authorization or a denial within twelve hours of the request. For retrospective certification requests after the discharge, the hospital or hospital unit must submit all the required clinical information to the MHD designee within thirty days of discharge. The MHD designee provides a response within thirty days of the receipt of the required clinical documentation. All retrospective certifications must meet the requirements in this section. An authorization or denial is based on the client's condition and the services provided at the time of admission and over the course of the hospital stay, until the date of notification or discharge, as applicable. .in accordance with the requirements of this section, and bases an approval or denial: (a) On the client's condition at the time of admission to the hospital or hospital unit if the request is for retrospective authorization of admission; or (b) On the client's condition at the time of the end of the allowable day of service in that hospital or hospital unit if the request is for retrospective authorization for a length of stay extension or for a transfer.

     WAC 388-550-2600(8) (9).

     WAC 388-550-2600(9) (10).

     WAC 388-550-2600(10) (11).

     WAC 388-550-2600(11) (12) The number of paid initial days authorized for an involuntary psychiatric admission is limited to twenty days from the date of detention. If the length of stay exceeds twenty days, the The hospital provider or hospital unit provider must submit the extension certification authorization for continued inpatient psychiatric care form request a length of stay extension prior to the twentieth day of service twenty-four hours prior to the expiration of the previously authorized days. Extension requests may not be denied for a person detained under ITA unless a less restrictive alternative is identified by the MHD designee and approved by the court. Extension requests may not be denied for youths detained under ITA who have been referred to the children's long-term inpatient program unless a less restrictive alternative is identified by the MHD designee and approved by the court.

     WAC 388-550-2600(12) (13) The department pays the administrative day rate for any authorized days of voluntary inpatient psychiatric stay that meet the administrative day definition in WAC 388-550-1050, and when all of the following conditions are met: (a) The client's legal status is voluntary admission; (b) The client's condition is no longer medically necessary; (c) The client's condition no longer meets the intensity of service criteria; (d) Less restrictive alternative treatments are not available, posing barrier to the client's safe discharge; and (e) The hospital or hospital unit and the MHD designee mutually agree that the administrative day is appropriate.

     WAC 388-550-2600(13) (14) The hospital provider or hospital unit provider will use the MHD approved due process for conflict resolution regarding medical necessity determinations provided by the MHD designee.

     WAC 388-550-2600(14) (15) In order for a an MHD designee...plan of care, a the hospital...

     WAC 388-550-2600(15) (16) If the number of...

     A final cost-benefit analysis is available by contacting Larry Linn, P.O. Box 45510, Olympia, WA 98504-5510, phone (360) 725-1856, fax (360) 753-9152, e-mail linnld@dshs.wa.gov.

     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 3, 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 3, Repealed 0.

     Date Adopted: June 25, 2007.

Robin Arnold-Williams

Secretary

     (a) Pays for the admission of an eligible medical assistance client to a hospital only when the client's attending physician orders admission and when the admission and treatment provided ((meet the requirements of)):

     (i) Are covered according to WAC 388-501-0050, 388-501-0060 and 388-501-0065;

     (ii) Are medically necessary as defined in WAC 388-500-0005;

     (iii) Are determined according to WAC 388-501-0165 when prior authorization is required;

     (iv) Are authorized when required under this chapter; and

     (v) Meet applicable state and federal requirements.

     (b) For ((nonemergent)) hospital admissions, defines "attending physician" ((means)) as the client's primary care provider, or the primary provider of care to the client at the time of ((hospitalization. For emergent admissions, "attending physician" means the staff member who has hospital admitting privileges and evaluates the client's medical condition upon the client's arrival at the hospital)) admission.

     (2) Medical record documentation of hospital services must meet the requirements in WAC 388-502-0020(((1), Records and reports -- Medical record system)).

     (3) ((In areas where the choice of hospitals is limited by managed care or selective contracting, the department is not responsible for payment under fee-for-service for hospital care and/or services:

     (a) Provided to clients enrolled in an MAA managed care plan, unless the services are excluded from the health carrier's capitation contract with MAA and are covered under the medical assistance program; or)) The department:

     (a) Pays for a hospital covered service provided to an eligible medical assistance client enrolled in a department managed care organization (MCO) plan, under the fee-for-service program if the service is excluded from the MCO's capitation contract with the department and meets prior authorization requirements. (See WAC 388-550-2600 for inpatient psychiatric services.)

     (b) ((Received by a Medicaid-eligible)) Does not pay for nonemergency services provided to a medical assistance client from a nonparticipating hospital in a selective contracting area (SCA) unless exclusions in WAC 388-550-4600 and 388-550-4700 apply. The department's selective contracting program and selective contracting payment limitations end for hospital claims with dates of admission before July 1, 2007.

     (4) The department ((provides chemical-dependent pregnant Medicaid-eligible clients)) pays up to twenty-six days of inpatient hospital care for hospital-based detoxification, medical stabilization, and drug treatment ((when:

     (a) An alcoholism, drug addiction and treatment support act ADATSA assessment center verifies the need for the inpatient care; and

     (b) The hospital chemical dependency treatment unit is certified by the division of alcohol and substance abuse)) for chemical dependent pregnant clients eligible under the chemical-using pregnant (CUP) women program.

     See ((WAC 388-550-6250 for outpatient hospital services for chemical-dependent pregnant Medicaid clients)) WAC 388-533-0701 through 0730.

     (5) The department ((covers)) pays for inpatient hospital detoxification of acute alcohol or other drug intoxication ((only in a hospital having a detoxification provider agreement with MAA to perform these services)) when the services are provided to an eligible client:

     (a) In a detoxification unit in a hospital that has a detoxification provider agreement with the department to perform these services and the services are approved by the division of alcohol and substance abuse (DASA); or

     (b) In an acute hospital and all of the following criteria are met:

     (i) The hospital does not have a detoxification specific provider agreement with DASA;

     (ii) The hospital provides the care in a medical unit;

     (iii) Non-hospital based detoxification is not medically appropriate for the client;

     (iv) The client does not require medically necessary inpatient psychiatric care and it is determined that an approval from a regional support network (RSN) or a mental health division (MHD) designee as an inpatient stay is not indicated;

     (v) The client's stay qualifies as an inpatient stay;

     (vi) The client is not participating in the department's chemical-using pregnant (CUP) women program; and

     (vii) The client's principal diagnosis meets the department's medical inpatient detoxification criteria listed in the department's published billing instructions.

     (6) The department covers medically necessary dental-related services provided to an eligible client((s)) in a ((hospital setting for the care or treatment of teeth, jaws, or structures directly supporting the teeth:

     (a) If the procedure requires hospitalization; and

     (b) A physician or dentist provides or directly supervises such services)) hospital-based dental clinic when the services:

     (a) Are provided in accordance with chapter 388-535 WAC; and

     (b) Are billed on the American Dental Association (ADA) or health care financing administration (HCFA) claim form.

     (7) The department pays a hospital((s)) for covered dental-related services ((provided in special care units when the provisions in WAC 388-550-2900(13) are met)), including oral and maxillofacial surgeries, that are provided in the hospital's operating room, when:

     (a) The covered dental-related services are medically necessary and provided in accordance with chapter 388-535 WAC;

     (b) The covered dental-related services are billed on a UB claim form; and

     (c) At least on of the following is true:

     (i) The dental-related service(s) is provided to an eligible medical assistance client on an emergency basis;

     (ii) The client is eligible under the division of developmental disability program;

     (iii) The client is age eight or younger; or

     (iv) The dental service is prior authorized by the department.

     (8) ((All services are subject to review and approval as stated in WAC 388-501-0050.

     (9))) For inpatient voluntary or involuntary psychiatric admissions, see WAC 388-550-2600 ((and chapter 246-318 WAC)).

[Statutory Authority: RCW 74.08.090 and 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, .11303, and .2652. 01-16-142, § 388-550-1100, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW 74.08.090. 01-02-075, § 388-550-1100, filed 12/29/00, effective 1/29/01. 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, § 388-550-1100, filed 12/18/97, effective 1/18/98.]

     (16) If the number of days billed exceeds the number of days authorized by the MHD designee for any claims paid, the department will recover any unauthorized days paid.

[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, § 388-550-2600, filed 12/18/97, effective 1/18/98.]

     (a) The medicaid base community psychiatric hospital payment rate is a minimum per diem for claims for psychiatric services provided to medicaid and SCHIP covered patients, paid to hospitals that accept commitments under the involuntary treatment act (ITA).

     (b) The non-medicaid base community psychiatric hospital payment rate is a minimum allowable per diem for claims for psychiatric services provided to indigent patients paid to hospitals that accept commitments under the ITA.

     (2) For the purposes of this section, "allowable" means the calculated allowed amount for payment based on the payment method before adjustments, deductions, or add-ons.

     (3) To be eligible for payment under the base community psychiatric hospitalization payment method:

     (a) A client's inpatient psychiatric voluntary hospitalization must:

     (i) Be medically necessary as defined in WAC 388-500-0005. In addition, the department considers medical necessity to be met when:

     (A) Ambulatory care resources available in the community do not meet the treatment needs of the client;

     (B) Proper treatment of the client's psychiatric condition requires services on an inpatient basis under the direction of a physician;

     (C) The inpatient services can be reasonably expected to improve the client's condition or prevent further regression so that the services will no longer be needed; and

     (D) The client, at the time of admission, is diagnosed as having an emotional/behavioral disturbance as a result of a mental disorder as defined in the current published Diagnostic and Statistical Manual of the American Psychiatric Association. The department does not consider detoxification to be psychiatric in nature.

     (ii) Be approved by the professional in charge of the hospital or hospital unit.

     (iii) Be authorized by the appropriate mental health division (MHD) designee prior to admission for covered diagnoses.

     (iv) Meet the criteria in WAC 388-550-2600.

     (b) A client's inpatient psychiatric involuntary hospitalization must:

     (i) Be in accordance with the admission criteria in chapters 71.05 and 71.34 RCW.

     (ii) Be certified by a MHD designee.

     (iii) Be approved by the professional in charge of the hospital or hospital unit.

     (iv) Be prior authorized by the regional support network (RSN) or its designee.

     (v) Meet the criteria in WAC 388-550-2600.

     (4) The provider requesting payment must complete the appropriate sections of the Involuntary Treatment Act patient claim information (form DSHS 13-628) in triplicate and route both the form and each claim form submitted for payment, to the county involuntary treatment office.

     (5) Payment for all claims is based on covered days within a client's approved length of stay (LOS), subject to client eligibility and department-covered services.

     (6) The medicaid base community psychiatric hospitalization payment rate applies only to a medicaid or SCHIP client admitted to a non-state-owned free-standing psychiatric hospital located in Washington state.

     (7) The non-medicaid base community psychiatric hospitalization payment rate applies only to a non-medicaid or SCHIP client admitted to a hospital:

     (a) Designated by the department as an ITA-certified hospital; or

     (b) That has a department-certified ITA bed that was used to provide ITA services at the time of the non-medicaid or non-SCHIP admission.

     (8) For inpatient hospital psychiatric services provided to eligible clients for dates of admission on and after July 1, 2005, through June 30, 2007, the department pays:

     (a) A hospital's department of health (DOH)-certified distinct psychiatric unit as follows:

     (i) For medicaid and SCHIP clients, inpatient hospital psychiatric services are paid using the department-specific non-diagnosis related group (DRG) payment method.

     (ii) For non-medicaid and non-SCHIP clients, the allowable for inpatient hospital psychiatric services is the greater of:

     (A) The state-((only))administered program DRG allowable (including the high cost outlier allowable, if applicable), or the department-specified non-DRG payment method if no relative weight exists for the DRG in the department's payment system; or

     (B) The non-medicaid base community psychiatric hospitalization payment rate multiplied by the covered days.

     (b) A hospital without a DOH-certified distinct psychiatric unit as follows:

     (i) For medicaid and SCHIP clients, inpatient hospital psychiatric services are paid using:

     (A) The DRG payment method; or

     (B) The department-specified non-DRG payment method if no relative weight exists for the DRG in the department's payment system.

     (ii) For non-medicaid and SCHIP clients, the allowable for inpatient hospital psychiatric services is the greater of:

     (A) The state-((only))administered program DRG allowable (including the high cost outlier allowable, if applicable), or the department-specified non-DRG payment method if no relative weight exists for the DRG in the department's payment system; or

     (B) The non-medicaid base community psychiatric hospitalization payment rate multiplied by the covered days.

     (c) A non-state-owned free-standing psychiatric hospital as follows:

     (i) For medicaid and SCHIP clients, inpatient hospital psychiatric services are paid using as the allowable, the greater of:

     (A) The ratio of costs-to-charges (RCC) allowable; or

     (B) The medicaid base community psychiatric hospitalization payment rate multiplied by covered days.

     (ii) For non-medicaid and non-SCHIP clients, inpatient hospital psychiatric services are paid the same as for medicaid and SCHIP clients, except the base community inpatient psychiatric hospital payment rate is the non-medicaid rate, and the RCC allowable is the state-((only))administered program RCC allowable.

     (d) A hospital, or a distinct psychiatric unit of a hospital, that is participating in the certified public expenditure (CPE) payment program, as follows:

     (i) For medicaid and SCHIP clients, inpatient hospital psychiatric services are paid using the methods identified in WAC 388-550-4650.

     (ii) For non-medicaid and non-SCHIP clients, inpatient hospital psychiatric services are paid using the methods identified in WAC 388-550-4650 in conjunction with the non-medicaid base community psychiatric hospitalization payment rate multiplied by covered days.

     (e) A hospital, or a distinct psychiatric unit of a hospital, that is participating in the critical access hospital (CAH) program, as follows:

     (i) For medicaid and SCHIP clients, inpatient hospital psychiatric services are paid using the department-specified non-DRG payment method.

     (ii) For non-medicaid non-SCHIP clients, inpatient hospital psychiatric services are paid using the department-specified non-DRG payment method.

[Statutory Authority: RCW 74.08.090, 74.09.500, and 2005 c 518, § 204, Part II. 07-06-043, § 388-550-2650, filed 3/1/07, effective 4/1/07.]

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