SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Effective Date of Rule: Thirty-one days after filing.
Purpose: The proposed rule does the following:
|•||Clearly states the department determines the appropriate payment enhancement percentage for physician trauma services.|
|•||Ensures the deadline for adjusting qualified trauma claims submitted to the health and recovery services.|
|•||Administration by physicians and other clinical providers are consistent with the deadline for trauma claims submitted by hospitals.|
|•||Adds cross-references to WAC 388-502-0150 (3) and (7) for clarification.|
Citation of Existing Rules Affected by this Order: Amending WAC 388-531-2000.
Statutory Authority for Adoption: RCW 74.08.090 and 74.09.500.
Other Authority: Chapter 43.20A RCW.
Adopted under notice filed as WSR 08-05-105 on February 19, 2008.
A final cost-benefit analysis is available by contacting Jonell O. Blatt, P.O. Box 45504, Olympia, WA 98504-5504, phone (360) 725-1571, fax (360) 586-9727, e-mail email@example.com. The preliminary cost-benefit analysis (CBA) stands as the final CBA.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.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: August 27, 2008.
(2) Beginning with services provided after June 30, 2003, the department makes increased payments from the TCF to physicians and other clinical providers who provide trauma services to Medicaid, GA-U, and ADATSA clients, subject to the provisions in this section. A provider is eligible to receive increased payments from the TCF for trauma services provided to a GA-U or ADATSA client during the client's certification period only. See WAC 388-416-0010.
(3) The department makes increased payments from the TCF to physicians and other clinical providers who:
(a) Are on the designated trauma services response team of any department of health (DOH)-designated trauma service center;
(b) Meet the provider requirements in this section and other applicable WAC;
(c) Meet the billing requirements in this section and other applicable WAC; and
(d) Submit all information the department requires to ensure trauma services are being provided.
(4) Except as described in subsection (5) of this section and subject to the limitations listed, the department makes increased payments from the TCF to physicians and other eligible clinical providers:
(a) For only those trauma services that are designated by the department as "qualified." These qualified services must be provided to eligible fee-for-service Medicaid, GA-U, and ADATSA clients. Qualified trauma services include care provided within six months of the date of injury for surgical procedures related to the injury if the surgical procedures were planned during the initial acute episode of injury.
(b) For hospital-based services only.
(c) Only for trauma cases that meet the injury severity score (ISS) (a summary rating system for traumatic anatomic injuries) of:
(i) Thirteen or greater for an adult trauma patient (a client age fifteen or older); or
(ii) Nine or greater for a pediatric trauma patient (a client younger than age fifteen).
(d) On a per-client basis in any DOH designated trauma service center.
(e) At a rate of two and one-half times the current
department fee-for-service rate for qualified trauma services,
subject to the following:)) or other payment enhancement
percentage the department determines as appropriate.
(i) The department monitors the increased payments from the TCF during each state fiscal year (SFY) and makes necessary adjustments to the rate to ensure that total payments from the TCF for the biennium will not exceed the legislative appropriation for that biennium.
(ii) Laboratory and pathology charges are not eligible for increased payments from the TCF. (See subsection (6)(b) of this section.)
(5) When a trauma case is transferred from one hospital to another, the department makes increased payments from the TCF to physicians and other eligible clinical providers, according to the ISS score as follows:
(a) If the transferred case meets or exceeds the appropriate ISS threshold described in subsection (4)(c) of this section, eligible providers who furnish qualified trauma services in both the transferring and receiving hospitals are eligible for increased payments from the TCF.
(b) If the transferred case is below the ISS threshold described in subsection (4)(c) of this section, only the eligible providers who furnish qualified trauma services in the receiving hospital are eligible for increased payments from the TCF.
(6) The department distributes increased payments from the TCF only:
(a) When eligible trauma claims are submitted with the appropriate trauma indicator within the time frames specified by the department; and
(b) On a per-claim basis. Each qualifying trauma service and/or procedure on the physician's claim or other clinical provider's claim is paid at the department's current fee-for-service rate, multiplied by an increased TCF payment rate that is based on the appropriate rate described in subsection (4)(e) of this section. Charges for laboratory and pathology services and/or procedures are not eligible for increased payments from the TCF and are paid at the department's current fee-for-service rate.
(7) For purposes of the increased payments from the TCF to physicians and other eligible clinical providers, all of the following apply:
(a) The department may consider a request for a claim adjustment submitted by a provider only if the claim is received by the department within one year from the date of the initial trauma service;
(b) The department does not allow any carryover of
liabilities for an increased payment from the TCF ((
date specified by the department as the last date to make))
beyond three hundred sixty-five days from the date of service.
The deadline for making adjustments to a trauma claim for an
SFY is the same as the deadline for submitting the initial
claim to the department as specified in WAC 388-502-0150(3). WAC 388-502-0150(7) does not apply (( in this case)) to TCF
(c) All claims and claim adjustments are subject to federal and state audit and review requirements; and
(d) The total amount of increased payments from the TCF disbursed to providers by the department in a biennium cannot exceed the amount appropriated by the legislature for that biennium. The department has the authority to take whatever actions are needed to ensure the department stays within the current TCF appropriation (see subsection (4)(e)(i) of this section).
[Statutory Authority: RCW 74.08.090, 74.09.500. 05-20-050, § 388-531-2000, filed 9/30/05, effective 10/31/05; 04-19-113, § 388-531-2000, filed 9/21/04, effective 10/22/04.]