Original Notice.

     Exempt from preproposal statement of inquiry under RCW 34.05.310(4).

     Title of Rule and Other Identifying Information: WAC 388-501-0135, 388-501-0200, 388-502-0100, 388-502-0120, 388-502-0150, 388-502-0160, 388-502-0210, 388-502-0220, 388-531-0050, 388-531-0150, 388-531-0200, 388-531-0300, 388-531-0350, 388-531-0450, 388-531-0500, 388-531-0550, 388-531-0600, 388-531-0650, 388-531-0700, 388-531-0750, 388-531-0800, 388-531-0850, 388-531-0900, 388-531-0950, 388-531-1050, 388-531-1100, 388-531-1150, 388-531-1200, 388-531-1250, 388-531-1300, 388-531-1350, 388-531-1450, 388-531-1500, 388-531-1550, 388-531-1650, 388-531-1700, 388-531-1750, 388-531-1850, 388-531-1900, 388-532-730, 388-532-760, 388-534-0200, 388-539-0200, 388-539-0300, 388-539-0350, 388-551-1350, 388-533-100, 388-533-300, 388-533-400, and 388-556-0200.

     Hearing Location(s): Blake Office Park East, Rose Room, 4500 10th Avenue S.E., Lacey, WA 98503 (one block north of the intersection of Pacific Avenue S.E. and Alhadeff Lane. A map or directions are available at http://www.dshs.wa.gov/msa/rpau/docket.html or by calling (360) 664-6094), on August 24, 2010, at 10:00 a.m.

     Date of Intended Adoption: Not sooner than August 25, 2010.

     Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504-5850, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail DSHSRPAURulesCoordinator@dshs.wa.gov, fax (360) 664-6185, by 5 p.m. on August 24, 2010.

     Assistance for Persons with Disabilities: Contact Jennisha Johnson, DSHS rules consultant, by August 10, 2010, TTY (360) 664-6178 or (360) 664-6094 or by e-mail at johnsjl4@dshs.wa.gov.

     Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: Correcting old terminology such as "medical assistance administration (MAA)" to "the department," "internal control number" to "a transaction control number," "medical identification card" to "services card," "foster care placement" to "in out-of-home placement," "EPSDT screens" to "EPSDT exams," fixing errant WAC cross references, adding updated web site links, and removing erroneous addresses.

     Reasons Supporting Proposal: Conforms to the new ProviderOne claims processing system and will eliminate confusion for people who read these rules by using correct citations and using uniform terminology.

     Statutory Authority for Adoption: RCW 74.08.090.

     Statute Being Implemented: RCW 74.08.090.

     Rule is not necessitated by federal law, federal or state court decision.

     Name of Proponent: Department of social and health services, governmental.

     Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Wendy L. Boedigheimer, P.O. Box 45504, Olympia, WA 98504-5504, (360) 725-1306.

     No small business economic impact statement has been prepared under chapter 19.85 RCW. These are just "housekeeping" changes.

     A cost-benefit analysis is not required under RCW 34.05.328. Because there are just "housekeeping" changes, it is exempt under RCW 34.05.328 (5)(b)(iv).

June 9, 2010

Katherine I. Vasquez

Rules Coordinator

     (a) PRC applies to medical assistance fee-for-service and managed care clients. PRC does not apply to clients eligible for the family planning only program.

     (b) PRC is authorized under federal medicaid law by 42 USC 1396n (a)(2) and 42 CFR 431.54.

     (2) Definitions. The following definitions apply to this section only:

     "Appropriate use" -- Use of healthcare services that are adapted to or appropriate for a client's healthcare needs.

     "Assigned provider" -- A department-enrolled healthcare provider or one participating with a department contracted managed care organization (MCO) who agrees to be assigned as a primary provider and coordinator of services for a fee-for-service or managed care client in the PRC program. Assigned providers can include a primary care provider (PCP), a pharmacy, a controlled substances prescriber, and a hospital for nonemergent hospital services.

     "At-risk" -- A term used to describe one or more of the following:

     (a) A client with a medical history of:

     • Indications of forging or altering prescriptions;

     • Seeking and/or obtaining healthcare services at a frequency or amount that is not medically necessary;

     • Potential life-threatening events or life-threatening conditions that required or may require medical intervention.

     (b) Behaviors or practices that could jeopardize a client's medical treatment or health including, but not limited to:

     • Referrals from social services personnel about inappropriate behaviors or practices that places the client at risk;

     • Noncompliance with treatment;

     • Paying cash for controlled substances;

     • Positive urine drug screen for illicit street drugs or nonprescribed controlled substances; or

     • Unauthorized use of a client's ((medical assistance identification)) services card or for an unauthorized purpose.

     "Care management"--Services provided to clients with multiple health, behavioral, and social needs in order to improve care coordination, client education, and client self-management skills.

     "Client" -- A person enrolled in a department healthcare program and receiving service from fee-for-service provider(s) or a managed care organization (MCO), contracted with the department.

     "Conflicting" -- Drugs and/or healthcare services that are incompatible and/or unsuitable for use together because of undesirable chemical or physiological effects.

     "Contraindicated" -- To indicate or show a medical treatment or procedure is inadvisable or not recommended or warranted.

     "Controlled substances prescriber" -- Any of the following healthcare professionals who, within their scope of professional practice, are licensed to prescribe and administer controlled substances (see chapter 69.50 RCW, uniform controlled substance act) for a legitimate medical purpose:

     • A physician under chapter 18.71 RCW;

     • A physician assistant under chapter 18.71A RCW;

     • An osteopathic physician under chapter 18.57 RCW;

     • An osteopathic physician assistant under chapter 18.57A RCW; and

     • An advanced registered nurse practitioner under chapter 18.79 RCW.

     "Duplicative" -- Applies to the use of the same or similar drugs and healthcare services without due justification. Example: A client receives healthcare services from two or more providers for the same or similar condition(s) in an overlapping time frame, or the client receives two or more similarly acting drugs in an overlapping time frame, which could result in a harmful drug interaction or an adverse reaction.

     "Just cause" -- A legitimate reason to justify the action taken, including but not limited to, protecting the health and safety of the client.

     "Managed care organization" or "MCO" -- An organization having a certificate of authority or certificate of registration from the office of insurance commissioner, that contracts with the department under a comprehensive risk contract to provide prepaid healthcare services to eligible medical assistance clients under the department's managed care programs.

     "Managed care client" -- A medical assistance client enrolled in, and receiving healthcare services from, a department-contracted managed care organization (MCO).

     "Primary care provider" or "PCP" -- A person licensed or certified under Title 18 RCW including, but not limited to, a physician, an advanced registered nurse practitioner (ARNP), or a physician assistant who supervises, coordinates, and provides healthcare services to a client, initiates referrals for specialty and ancillary care, and maintains the client's continuity of care.

     (3) Clients selected for PRC review. The department or MCO selects a client for PRC review when either or both of the following occur:

     (a) A utilization review report indicates the client has not utilized healthcare services appropriately; or

     (b) Medical providers, social service agencies, or other concerned parties have provided direct referrals to the department or MCO.

     (4) When a fee-for-service client is selected for PRC review the prior authorization process as defined in chapter 388-530 WAC may be required:

     (a) Prior to or during a PRC review; or

     (b) When currently in the PRC program.

     (5) Review for placement in the PRC program. When the department or MCO selects a client for PRC review, the department or MCO staff, with clinical oversight, reviews a client's medical and/or billing history to determine if the client has utilized healthcare services at a frequency or amount that is not medically necessary (42 CFR 431.54(e)).

     (6) Utilization guidelines for PRC placement. Department or MCO staff use the following utilization guidelines to determine PRC placement. A client may be placed in the PRC program when medical and/or billing histories document any of the following:

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

     (i) Received services from four or more different providers, including physicians, advanced registered nurse practitioners (ARNPs), and physician assistants (PAs);

     (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;

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

     (vi) Had ten or more office visits.

     (b) Any one of the following occurred within a period of ninety consecutive calendar days in the previous twelve months. The client:

     (i) Made two or more emergency department visits;

     (ii) Has a medical history that indicates "at-risk" utilization patterns;

     (iii) Made repeated and documented efforts to seek healthcare services that are not medically necessary; or

     (iv) Has been counseled at least once by a health care provider, or a department or MCO staff member, with clinical oversight, about the appropriate use of healthcare services.

     (c) The client received prescriptions for controlled substances from two or more different prescribers in any one month in a period of ninety consecutive days in the previous twelve months.

     (d) The client's medical and/or billing history demonstrates a pattern of the following at any time in the previous twelve months:

     (i) The client has a history of using healthcare services in a manner that is duplicative, excessive, or contraindicated; or

     (ii) The client has a history of receiving conflicting healthcare services, drugs, or supplies that are not within acceptable medical practice.

     (7) PRC review results. As a result of the PRC review, the department or MCO staff may take any of the following steps:

     (a) Determine that no action is needed and close the client's file;

     (b) Send the client and, if applicable, the client's authorized representative, a letter of concern with information on specific findings and notice of potential placement in the PRC program; or

     (c) Determine that the utilization guidelines for PRC placement establish that the client has utilized healthcare services at an amount or frequency that is not medically necessary, in which case the department or MCO will take one or more of the following actions:

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

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

     (iii) Place the client into the PRC program for an initial placement period of twenty-four months.

     (8) Initial placement in the PRC program. When a client is initially placed in the PRC program:

     (a) The department or MCO places the client for twenty-four months with one or more of the following types of healthcare providers:

     (i) Primary care provider (PCP) (as defined in subsection (2) of this section);

     (ii) Pharmacy;

     (iii) Controlled substances prescriber;

     (iv) Hospital (for nonemergent hospital services); or

     (v) Another qualified provider type, as determined by department or MCO program staff on a case-by-case basis.

     (b) The managed care client will remain in the same MCO for no less than twelve months unless:

     (i) The client moves to a residence outside the MCO's service area and the MCO is not available in the new location; or

     (ii) The client's assigned provider no longer participates with the MCO and is available in another MCO, and the client wishes to remain with the current provider.

     (c) A managed care client placed in the PRC program must remain in the PRC program for the initial twenty-four month period regardless of whether the client changes MCOs or becomes a fee-for-service client.

     (d) A care management program may be offered to a client.

     (9) Notifying the client about placement in the PRC program. When the client is initially placed in the PRC program, the department or the MCO sends the client and, if applicable, the client's authorized representative, a written notice containing at least the following components:

     (a) Informs the client of the reason for the PRC program placement;

     (b) Directs the client to respond to the department or MCO within ten business days of the date of the written notice about taking the following actions:

     (i) Select providers, subject to department or MCO approval;

     (ii) Submit additional healthcare information, justifying the client's use of healthcare services; or

     (iii) Request assistance, if needed, from the department or MCO program staff.

     (c) Informs the client of hearing or appeal rights (see subsection (14) of this section).

     (d) Informs the client that if a response is not received within ten days of the date of the notice, the client will be assigned a provider(s) by the department or MCO.

     (10) Selection and role of assigned provider. A client may be afforded a limited choice of providers.

     (a) The following providers are not available:

     (i) A provider who is being reviewed by the department or licensing authority regarding quality of care;

     (ii) A provider who has been suspended or disqualified from participating as a department-enrolled or MCO-contracted provider; or

     (iii) A provider whose business license is suspended or revoked by the licensing authority.

     (b) For a client placed in the PRC program, the assigned:

     (i) Provider(s) must be located in the client's local geographic area, in the client's selected MCO, and/or be reasonably accessible to the client.

     (ii) Primary care provider (PCP) supervises and coordinates healthcare services for the client, including continuity of care and referrals to specialists when necessary. The PCP must be one of the following:

     (A) A physician who meets the criteria as defined in chapter 388-502 WAC;

     (B) An advanced registered nurse practitioner (ARNP) who meets the criteria as defined in chapter 388-502 WAC; or

     (C) A licensed physician assistant (PA), practicing with a supervising physician.

     (iii) Controlled substances prescriber prescribes all controlled substances for the client.

     (iv) Pharmacy fills all prescriptions for the client.

     (v) Hospital provides all nonemergent hospital services.

     (c) A client placed in the PRC program cannot change assigned providers for twelve months after the assignments are made, unless:

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

     (ii) The provider moves out of the client's local geographic area and is no longer reasonably accessible to the client;

     (iii) The provider refuses to continue to serve the client;

     (iv) The client did not select the provider. The client may request to change an assigned provider once within thirty calendar days of the initial assignment;

     (v) The client's assigned provider no longer participates with the MCO. In this case, the client may select a new provider from the list of available providers in the MCO or follow the assigned provider to the new MCO.

     (d) When an assigned prescribing provider no longer contracts with the department:

     (i) All prescriptions from the provider are invalid thirty calendar days following the date the contract ends; and

     (ii) All prescriptions from the provider are subject to applicable prescription drugs (outpatient) rules in chapter 388-530 WAC or appropriate MCO rules.

     (iii) The client must choose or be assigned another provider according to the requirements in this section.

     (11) PRC placement periods. The length of time for a client's PRC placement includes:

     (a) The initial period of PRC placement, which is a minimum of twenty-four consecutive months.

     (b) The second period of PRC placement, which is an additional thirty-six consecutive months.

     (c) The third period and each subsequent period of PRC placement, which is an additional seventy-two months.

     (12) Department review of a PRC placement period. The department or MCO reviews a client's use of healthcare services prior to the end of each PRC placement period described in subsection (11) of this section using the utilization guidelines in subsection (6) of this section.

     (a) The department or MCO assigns the next PRC placement period if the utilization guidelines for PRC placement in subsection (6) apply to the client.

     (b) When the department or MCO assigns a subsequent PRC placement period, the department or MCO sends the client and, if applicable, the client's authorized representative, a written notice informing the client:

     (i) The reason for the subsequent PRC program placement;

     (ii) The length of the subsequent PRC placement;

     (iii) That the current providers assigned to the client continue to be assigned to the client during the subsequent PRC placement period;

     (iv) That all PRC program rules continue to apply; and

     (v) Of hearing or appeal rights (see subsection (14) of this section);

     (vi) Of the rules that support the decision.

     (c) The department may remove a client from PRC placement if the client:

     (i) Successfully completes a treatment program that is provided by a chemical dependency service provider certified by the department under chapter 388-805 WAC;

     (ii) Submits documentation of completion of the approved treatment program to the department; and

     (iii) Maintains appropriate use of healthcare services within the utilization guidelines described in subsection (6) for six months after the date the treatment ends.

     (d) The department or MCO determines the appropriate placement period for a client who has been placed back into the program.

     (e) A client will remain placed in the PRC program regardless of change in eligibility program type or change in address.

     (13) Client financial responsibility. A client placed in the PRC program may be billed by a provider and held financially responsible for healthcare services when the client obtains nonemergent services and the provider who renders the services is not assigned or referred under the PRC program.

     (14) Right to hearing or appeal.

     (a) A fee-for-service client who believes the department has taken an invalid action pursuant to this section may request a hearing.

     (b) A managed care client who believes the MCO has taken an invalid action pursuant to this section or chapter 388-538 WAC must exhaust the MCO's internal appeal process set forth in WAC 388-538-110 prior to requesting a hearing. Managed care clients can not change MCOs until the appeal or hearing is resolved and there is a final ruling.

     (c) A client must request the hearing or appeal within ninety calendar days after the client receives the written notice of placement in the PRC program.

     (d) The department conducts a hearing according to chapter 388-02 WAC. Definitions for the terms "hearing," "initial order," and "final order" used in this subsection are found in WAC 388-02-0010.

     (e) A client who requests a hearing or appeal within ten calendar days from the date of the written notice of an initial PRC placement period under subsection (11)(a) of this section will not be placed in the PRC program until the date an initial order is issued that supports the client's placement in the PRC program or otherwise ordered by an administrative law judge (ALJ).

     (f) A client who requests a hearing or appeal more than ten calendar days from the date of the written notice under subsection (9) of this section will remain placed in the PRC program unless a final administrative order is entered that orders the client's removal from the program.

     (g) A client who requests a hearing or appeal within ninety days from the date of receiving the written notice under subsection (9) of this section and who has already been assigned providers will remain placed in the PRC program unless a final administrative order is entered that orders the client's removal from the program.

     (h) An administrative law judge (ALJ) may rule that the client be placed in the PRC program prior to the date the record is closed and prior to the date the initial order is issued based on a showing of just cause.

     (i) The client who requests a hearing challenging placement into the PRC program has the burden of proving the department's or MCO's action was invalid. For standard of proof, see WAC 388-02-0485.

[Statutory Authority: RCW 74.08.090 and 42 C.F.R. 431.51, 431.54(e) and 456.1; 42 U.S.C. 1396n. 08-05-010, § 388-501-0135, filed 2/7/08, effective 3/9/08. Statutory Authority: RCW 74.08.090, 74.09.520, 74.04.055, and 42 C.F.R. 431.54. 06-14-062, § 388-501-0135, filed 6/30/06, effective 7/31/06. Statutory Authority: RCW 74.08.090, 74.04.055, and 42 C.F.R. Subpart B 431.51, 431.54 (e) and (3), and 456.1. 04-01-099, § 388-501-0135, filed 12/16/03, effective 1/16/04. 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.]

     (2) ((MAA)) The department pays for medical services and seeks reimbursement from the liable third party when the claim is for any of the following:

     (a) Prenatal care;

     (b) Labor, delivery, and postpartum care (except inpatient hospital costs) for a pregnant woman; or

     (c) Preventive pediatric services as covered under the EPSDT program.

     (3) ((MAA)) The department pays for medical services and seeks reimbursement from any liable third party when both of the following apply:

     (a) The provider submits to ((MAA)) the department documentation of billing the third party and the provider has not received payment after thirty days from the date of services; and

     (b) The claim is for a covered service provided to a client on whose behalf the office of support enforcement is enforcing an absent parent to pay support. For the purpose of this section, "is enforcing" means the absent parent either:

     (i) Is not complying with an existing court order; or

     (ii) Received payment directly from the third party and did not pay for the medical services.

     (4) The provider may not bill ((MAA)) the department or the client for a covered service when a third party pays a provider the same amount as or more than the ((MAA)) department rate.

     (5) When the provider receives payment from the third party after receiving reimbursement from ((MAA)) the department, the provider must refund to ((MAA)) the department the amount of the:

     (a) Third-party payment when the payment is less than ((MAA's)) the department's maximum allowable rate; or

     (b) ((MAA)) The department payment when the third-party payment is equal to or greater than ((MAA's)) the department's maximum allowable rate.

     (6) ((MAA)) The department is not responsible to pay for medical services when the third-party benefits are available to pay for the client's medical services at the time the provider bills ((MAA)) the department, except as described under subsections (2) and (3) of this section.

     (7) The client is liable for charges for covered medical services that would be paid by the third party payment when the client either:

     (a) Receives direct third-party reimbursement for such services; or

     (b) Fails to execute legal signatures on insurance forms, billing documents, or other forms necessary to receive insurance payments for services rendered. See WAC 388-505-0540 for assignment of rights.

     (8) ((MAA)) The department considers an adoptive family to be a third-party resource for the medical expenses of the birth mother and child only when there is a written contract between the adopting family and either the birth mother, the attorney, the provider, or the adoption service. The contract must specify that the adopting family will pay for the medical care associated with the pregnancy.

     (9) A provider cannot refuse to furnish covered services to a client because of a third party's potential liability for the services.

     (10) For third-party liability on personal injury litigation claims, ((MAA)) the department is responsible for providing medical services as described under WAC 388-501-0100.

[Statutory Authority: RCW 74.04.050, 74.08.090. 00-11-141, § 388-501-0200, filed 5/23/00, effective 6/23/00; 00-01-088, § 388-501-0200, filed 12/14/99, effective 1/14/00.]

     (a) The service is within the scope of care of the client's medical assistance program;

     (b) The service is medically or dentally necessary;

     (c) The service is properly authorized;

     (d) The provider bills within the time frame set in WAC 388-502-0150;

     (e) The provider bills according to department rules and billing instructions; and

     (f) The provider follows third-party payment procedures.

     (2) The department is the payer of last resort, unless the other payer is:

     (a) An Indian health service;

     (b) A crime victims program through the department of labor and industries; or

     (c) A school district for health services provided under the Individuals with Disabilities Education Act.

     (3) The department does not reimburse providers for medical services identified by the department as client financial obligations, and deducts from the payment the costs of those services identified as client financial obligations. Client financial obligations include, but are not limited to, the following:

     (a) Copayments (co-pays) (unless the criteria in chapter 388-517 WAC or WAC 388-501-0200 are met);

     (b) Deductibles (unless the criteria in chapter 388-517 WAC or WAC 388-501-0200 are met);

     (c) Emergency medical expense requirements (EMER); and

     (d) Spenddown (see WAC 388-519-0110).

     (4) The provider must accept medicare assignment for claims involving clients eligible for both medicare and medical assistance before ((MAA)) the department makes any payment.

     (5) The provider is responsible for verifying whether a client has medical assistance coverage for the dates of service.

     (6) The department may reimburse a provider for services provided to a person if it is later determined that the person was ineligible for the service at the time it was provided if:

     (a) The department considered the person eligible at the time of service;

     (b) The service was not otherwise paid for; and

     (c) The provider submits a request for payment to the department.

     (7) The department does not pay on a fee-for-service basis for a service for a client who is enrolled in a managed care plan when the service is included in the plan's contract with the department.

     (8) Information about medical care for jail inmates is found in RCW 70.48.130.

     (9) The department pays for medically necessary services on the basis of usual and customary charges or the maximum allowable fee established by the department, whichever is lower.

[Statutory Authority: RCW 71.05.560, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. 06-13-042, § 388-502-0100, filed 6/15/06, effective 7/16/06. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.530. 00-15-050, § 388-502-0100, filed 7/17/00, effective 8/17/00.]

     (2) With the exception of hospital services and nursing facilities, the department pays the provider of service in designated bordering cities as if the care was provided within the state of Washington (see WAC 388-501-0175).

     (3) With the exception of designated bordering cities, the department does not pay for healthcare services provided to clients in medical care services (MCS) programs outside the state of Washington (see WAC 388-556-0500).

     (4) With the exception of hospital services (see subsection (5) of this section), the department pays for healthcare services provided outside the state of Washington at the lower of:

     (a) The billed amount; or

     (b) The rate established by the Washington state medical assistance programs.

     (5) The department pays for hospital services provided in designated bordering cities and outside the state of Washington in accordance with the provisions of WAC 388-550-3900, 388-550-4000, 388-550-4800 and 388-550-6700.

     (6) The department pays nursing facilities located outside the state of Washington when approved by the aging and disability services administration (ADSA) at the lower of the billed amount or the adjusted statewide average reimbursement rate for in-state nursing facility care, only in the following limited circumstances:

     (a) Emergency situations; or

     (b) When the client intends to return to Washington state and the out-of-state stay is for:

     (i) Thirty days or less; or

     (ii) More than thirty days if approved by ADSA.

     (7) To receive payment from the department, an out-of-state provider must:

     (a) Have a signed agreement with the department;

     (b) Meet the functionally equivalent licensing requirements of the state or province in which care is rendered;

     (c) Meet the conditions in WAC 388-502-0100 and 388-502-0150;

     (d) Satisfy all medicaid conditions of participation;

     (e) Accept the department's payment as payment in full according to 42 CFR 447.15; and

     (f) If a Canadian provider, bill at the U.S. exchange rate in effect at the time the service was provided.

     (8) For covered services for eligible clients, ((MAA)) the department reimburses other approved out-of-state providers at the lower of:

     (a) The billed amount; or

     (b) The rate paid by the Washington state Title XIX medicaid program.

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. 08-08-064, § 388-502-0120, filed 3/31/08, effective 5/1/08. Statutory Authority: RCW 74.08.090. 01-02-076, § 388-502-0120, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.04.050 and 74.08.090. 00-01-088, § 388-502-0120, filed 12/14/99, effective 1/14/00.]

     (1) The department requires providers to submit initial claims and adjust prior claims in a timely manner. The department has three timeliness standards:

     (a) For initial claims, see subsections (3), (4), (5), and (6) of this section;

     (b) For resubmitted claims other than prescription drug claims and claims for major trauma services, see subsections (7) and (8) of this section;

     (c) For resubmitted prescription drug claims, see subsections (9) and (10) of this section; and

     (d) For resubmitting claims for major trauma services, see subsection (11) of this section.

     (2) The provider must submit claims to the department as described in the department's current published billing instructions.

     (3) Providers must submit the initial claim to the department and have ((an internal)) a transaction control number (((ICN))) (TCN) assigned by the department within three hundred sixty-five calendar days from any of the following:

     (a) The date the provider furnishes the service to the eligible client;

     (b) The date a final fair hearing decision is entered that impacts the particular claim;

     (c) The date a court orders the department to cover the service; or

     (d) The date the department certifies a client eligible under delayed certification criteria.

     (4) The department may grant exceptions to the time limit of three hundred sixty-five calendar days for initial claims when billing delays are caused by either of the following:

     (a) The department's certification of a client for a retroactive period; or

     (b) The provider proves to the department's satisfaction that there are other extenuating circumstances.

     (5) The department requires providers to bill known third parties for services. See WAC 388-501-0200 for exceptions. Providers must meet the timely billing standards of the liable third parties in addition to the department's billing limits.

     (6) When a client is covered by both medicare and medicaid, the provider must bill medicare for the service before billing the initial claim to the department. If medicare:

     (a) Pays the claim the provider must bill the department within six months of the date medicare processes the claim; or

     (b) Denies payment of the claim, the department requires the provider to meet the three hundred sixty-five-day requirement for timely initial claims as described in subsection (3) of this section.

     (7) The following applies to claims with a date of service or admission before July 1, 2009:

     (a) Within thirty-six months of the date the service was provided to the client, a provider may resubmit, modify, or adjust any claim, other than a prescription drug claim or a claim for major trauma services, with a timely ((ICN)) TCN. This applies to any claim, other than a prescription drug claim or a claim for major trauma services, that met the time limits for an initial claim, whether paid or denied. The department does not accept any claim for resubmission, modification, or adjustment after the thirty-six-month period ends.

     (b) After thirty-six months from the date the service was provided to the client, a provider cannot refund overpayments by claim adjustment; a provider must refund overpayments by a negotiable financial instrument, such as a bank check.

     (8) The following applies to claims with a date of service or admission on or after July 1, 2009:

     (a) Within twenty-four months of the date the service was provided to the client, a provider may resubmit, modify, or adjust an initial claim, other than a prescription drug claim or a claim for major trauma services.

     (b) After twenty-four months from the date the service was provided to the client, the department does not accept any claim for resubmission, modification, or adjustment. This twenty-four-month period does not apply to overpayments that a provider must refund to the department by a negotiable financial instrument, such as a bank check.

     (9) The department allows providers to resubmit, modify, or adjust any prescription drug claim with a timely ((ICN)) TCN within fifteen months of the date the service was provided to the client. After fifteen months, the department does not accept any prescription drug claim for resubmission, modification or adjustment.

     (10) The fifteen-month period described in subsection (9) of this section does not apply to overpayments that a prescription drug provider must refund to the department. After fifteen months a provider must refund overpayments by a negotiable financial instrument, such as a bank check.

     (11) The department allows a provider of trauma care services to resubmit, modify, or adjust, within three hundred and sixty-five calendar days of the date of service, any trauma claim that meets the criteria specified in WAC 388-531-2000 (for physician claims) or WAC 388-550-5450 (for hospital claims) for the purpose of receiving payment from the trauma care fund (TCF).

     (a) No increased payment from the TCF is allowed for an otherwise qualifying trauma claim that is resubmitted after three hundred sixty-five calendar days from the date of service.

     (b) Resubmission of or any adjustments to a trauma claim for purposes other than receiving TCF payments are subject to the provisions of this section.

     (12) The three hundred sixty-five-day period described in subsection (11) of this section does not apply to overpayments from the TCF that a trauma care provider must refund to the department. A provider must refund an overpayment for a trauma claim that received payment from TCF using a method specified by the department.

     (13) If a provider fails to bill a claim according to the requirements of this section and the department denies payment of the claim, the provider or any provider's agent cannot bill the client or the client's estate. The client is not responsible for the payment.

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). 09-12-063, § 388-502-0150, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090 and 42 C.F.R. 447.45. 00-14-067, § 388-502-0150, filed 7/5/00, effective 8/5/00.]

     (a) Fee-for-service or managed care clients can choose to self-pay for medical assistance services; and

     (b) Providers (as defined in WAC 388-500-0005) have the authority to bill fee-for-service or managed care clients for medical assistance services furnished to those clients.

     (2) The provider is responsible for:

     (a) Verifying whether the client is eligible to receive medical assistance services on the date the services are provided;

     (b) Verifying whether the client is enrolled with a department-contracted managed care organization (MCO);

     (c) Knowing the limitations of the services within the scope of the eligible client's medical program (see WAC 388-501-0050 (4)(a) and 388-501-0065);

     (d) Informing the client of those limitations;

     (e) Exhausting all applicable department or department-contracted MCO processes necessary to obtain authorization for requested service(s);

     (f) Ensuring that translation or interpretation is provided to clients with limited English proficiency (LEP) who agree to be billed for services in accordance with this section; and

     (g) Retaining all documentation which demonstrates compliance with this section.

     (3) Unless otherwise specified in this section, providers must accept as payment in full the amount paid by the department or department-contracted MCO for medical assistance services furnished to clients. See 42 CFR § 447.15.

     (4) A provider must not bill a client, or anyone on the client's behalf, for any services until the provider has completed all requirements of this section, including the conditions of payment described in department's rules, the department's fee-for-service billing instructions, and the requirements for billing the department-contracted MCO in which the client is enrolled, and until the provider has then fully informed the client of his or her covered options. A provider must not bill a client for:

     (a) Any services for which the provider failed to satisfy the conditions of payment described in department's rules, the department's fee-for-service billing instructions, and the requirements for billing the department-contracted MCO in which the client is enrolled.

     (b) A covered service even if the provider has not received payment from the department or the client's MCO.

     (c) A covered service when the department denies an authorization request for the service because the required information was not received from the provider or the prescriber under WAC 388-501-0165 (7)(c)(i).

     (5) If the requirements of this section are satisfied, then a provider may bill a fee-for-service or a managed care client for a covered service, defined in WAC 388-501-0050(9), or a noncovered service, defined in WAC 388-501-0050(10) and 388-501-0070. The client and provider must sign and date the DSHS form 13-879, Agreement to Pay for Healthcare Services, before the service is furnished. DSHS form 13-879, including translated versions, is available to download at http://www1.dshs.wa.gov/msa/forms/eforms.html. The requirements for this subsection are as follows:

     (a) The agreement must:

     (i) Indicate the anticipated date the service will be provided, which must be no later than ninety calendar days from the date of the signed agreement;

     (ii) List each of the services that will be furnished;

     (iii) List treatment alternatives that may have been covered by the department or department-contracted MCO;

     (iv) Specify the total amount the client must pay for the service;

     (v) Specify what items or services are included in this amount (such as pre-operative care and postoperative care). See WAC 388-501-0070(3) for payment of ancillary services for a noncovered service;

     (vi) Indicate that the client has been fully informed of all available medically appropriate treatment, including services that may be paid for by the department or department-contracted MCO, and that he or she chooses to get the specified service(s);

     (vii) Specify that the client may request an exception to rule (ETR) in accordance with WAC ((388-526-2610)) 388-501-0160 when the department denies a request for a noncovered service and that the client may choose not to do so;

     (viii) Specify that the client may request an administrative hearing in accordance with WAC 388-526-2610 to appeal the department's denial of a request for prior authorization of a covered service and that the client may choose not to do so;

     (ix) Be completed only after the provider and the client have exhausted all applicable department or department-contracted MCO processes necessary to obtain authorization of the requested service, except that the client may choose not to request an ETR or an administrative hearing regarding department denials of authorization for requested service(s); and

     (((ix))) (x) Specify which reason in subsection (b) below applies.

     (b) The provider must select on the agreement form one of the following reasons (as applicable) why the client is agreeing to be billed for the service(s). The service(s) is:

     (i) Not covered by the department or the client's department-contracted MCO and the ETR process as described in WAC 388-501-0160 has been exhausted and the service(s) is denied;

     (ii) Not covered by the department or the client's department-contracted MCO and the client has been informed of his or her right to an ETR and has chosen not to pursue an ETR as described in WAC 388-501-0160;

     (iii) Covered by the department or the client's department-contracted MCO, requires authorization, and the provider completes all the necessary requirements; however the department denied the service as not medically necessary (this includes services denied as a limitation extension under WAC 388-501-0169); or

     (iv) Covered by the department or the client's department-contracted MCO and does not require authorization, but the client has requested a specific type of treatment, supply, or equipment based on personal preference which the department or MCO does not pay for and the specific type is not medically necessary for the client.

     (c) For clients with limited English proficiency, the agreement must be the version translated in the client's primary language and interpreted if necessary. If the agreement is translated, the interpreter must also sign it;

     (d) The provider must give the client a copy of the agreement and maintain the original and all documentation which supports compliance with this section in the client's file for six years from the date of service. The agreement must be made available to the department for review upon request; and

     (e) If the service is not provided within ninety calendar days of the signed agreement, a new agreement must be completed by the provider and signed by both the provider and the client.

     (6) There are limited circumstances in which a provider may bill a client without executing DSHS form 13-879, Agreement to Pay for Healthcare Services, as specified in subsection (5) of this section. The following are those circumstances:

     (a) The client, the client's legal guardian, or the client's legal representative:

     (i) Was reimbursed for the service directly by a third party (see WAC 388-501-0200); or

     (ii) Refused to complete and sign insurance forms, billing documents, or other forms necessary for the provider to bill the third party insurance carrier for the service.

     (b) The client represented himself/herself as a private pay client and not receiving medical assistance when the client was already eligible for and receiving benefits under a medical assistance program. In this circumstance, the provider must:

     (i) Keep documentation of the client's declaration of medical coverage. The client's declaration must be signed and dated by the client, the client's legal guardian, or the client's legal representative; and

     (ii) Give a copy of the document to the client and maintain the original for six years from the date of service, for department review upon request.

     (c) The bill counts toward the financial obligation of the client or applicant (such as spenddown liability, client participation as described in WAC 388-513-1380, emergency medical expense requirement, deductible, or copayment required by the department). See subsection (7) of this section for billing a medically needy client for spenddown liability;

     (d) The client is under the department's or a department-contracted MCO's patient review and coordination (PRC) program (WAC 388-501-0135) and receives nonemergency services from providers or healthcare facilities other than those to whom the client is assigned or referred under the PRC program;

     (e) The client is a dual-eligible client with medicare Part D coverage or similar creditable prescription drug coverage and the conditions of WAC 388-530-7700 (2)(a)(iii) are met;

     (f) The services provided to a TAKE CHARGE or family planning only client are not within the scope of the client's benefit package;

     (g) The services were noncovered ambulance services (see WAC 388-546-0250(2));

     (h) A fee-for-service client chooses to receive nonemergency services from a provider who is not contracted with the department after being informed by the provider that he or she is not contracted with the department and that the services offered will not be paid by the client's healthcare program; and

     (i) A department-contracted MCO enrollee chooses to receive nonemergency services from providers outside of the MCO's network without authorization from the MCO, i.e., a nonparticipating provider.

     (7) Under chapter 388-519 WAC, an individual who has applied for medical assistance is required to spend down excess income on healthcare expenses to become eligible for coverage under the medically needy program. An individual must incur healthcare expenses greater than or equal to the amount that he or she must spend down. The provider is prohibited from billing the individual for any amount in excess of the spenddown liability assigned to the bill.

     (8) There are situations in which a provider must refund the full amount of a payment previously received from or on behalf of an individual and then bill the department for the covered service that had been furnished. In these situations, the individual becomes eligible for a covered service that had already been furnished. Providers must then accept as payment in full the amount paid by the department or managed care organization for medical assistance services furnished to clients. These situations are as follows:

     (a) The individual was not receiving medical assistance on the day the service was furnished. The individual applies for medical assistance later in the same month in which the service was provided and the department makes the individual eligible for medical assistance from the first day of that month;

     (b) The client receives a delayed certification for medical assistance as defined in WAC 388-500-0005; or

     (c) The client receives a certification for medical assistance for a retroactive period according to 42 CFR § 435.914(a) and defined in WAC 388-500-0005.

     (9) Regardless of any written, signed agreement to pay, a provider may not bill, demand, collect, or accept payment or a deposit from a client, anyone on the client's behalf, or the department for:

     (a) Copying, printing, or otherwise transferring healthcare information, as the term healthcare information is defined in chapter 70.02 RCW, to another healthcare provider. This includes, but is not limited to:

     (i) Medical/dental charts;

     (ii) Radiological or imaging films; and

     (iii) Laboratory or other diagnostic test results.

     (b) Missed, cancelled, or late appointments;

     (c) Shipping and/or postage charges;

     (d) "Boutique," "concierge," or enhanced service packages (e.g., newsletters, 24/7 access to provider, health seminars) as a condition for access to care; or

     (e) The price differential between an authorized service or item and an "upgraded" service or item (e.g., a wheelchair with more features; brand name versus generic drugs).

[Statutory Authority: RCW 74.08.090 and 42 C.F.R. 447.15. 10-10-022, § 388-502-0160, filed 4/26/10, effective 5/27/10. Statutory Authority: RCW 74.08.090, 74.09.055, 2001 c 7, Part II. 02-12-070, § 388-502-0160, filed 5/31/02, effective 7/1/02. Statutory Authority: RCW 74.08.090. 01-21-023, § 388-502-0160, filed 10/8/01, effective 11/8/01; 01-05-100, § 388-502-0160, filed 2/20/01, effective 3/23/01. Statutory Authority: RCW 74.08.090 and 74.09.520. 00-14-069, § 388-502-0160, filed 7/5/00, effective 8/5/00.]

     (2) ((MAA)) The department analyzes the data collected from the providers' reports to secure statistics on costs of goods and services furnished and makes a report of the analysis available to ((MAA's)) the department's advisory committee, the state welfare medical care committee, representative organizations of provider groups enrolled with ((MAA)) the department, and any other interested organizations or individuals.

[Statutory Authority: RCW 74.08.090, 74.09.035. 00-15-049, § 388-502-0210, filed 7/17/00, effective 8/17/00. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-502-0210, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-020.]

     (2) The first level of appeal. A contractor/provider who wants to contest a reimbursement rate must file a written appeal with ((MAA)) the department.

     (a) The appeal must include all of the following:

     (i) A statement of the specific issue being appealed;

     (ii) Supporting documentation; and

     (iii) A request for ((MAA)) the department to recalculate the rate.

     (b) When a contractor/provider appeals a portion of a rate, ((MAA)) the department may review all components of the reimbursement rate.

     (c) In order to complete a review of the appeal, ((MAA)) the department may do one or both of the following:

     (i) Request additional information; and/or

     (ii) Conduct an audit of the documentation provided.

     (d) ((MAA)) The department issues a decision or requests additional information within sixty calendar days of receiving the rate appeal request.

     (i) When ((MAA)) the department requests additional information, the contractor/provider has forty-five calendar days from the date of ((MAA's)) the department's request to submit the additional information.

     (ii) ((MAA)) The department issues a decision within thirty calendar days of receipt of the completed information.

     (e) ((MAA)) The department may adjust rates retroactively to the effective date of a new rate or a rate change. In order for a rate increase to be retroactive, the contractor/provider must file the appeal within sixty calendar days of the date of the rate notification letter from ((MAA)) the department. ((MAA)) the department does not consider any appeal filed after the sixty day period to be eligible for retroactive adjustment.

     (f) ((MAA)) The department may grant a time extension for the appeal period if the contractor/provider makes such a request within the sixty-day period referenced under (e) of this subsection.

     (g) Any rate increase resulting from an appeal filed within the sixty-day period described in subsection (2)(e) of this section is effective retroactively to the rate effective date in the notification letter.

     (h) Any rate increase resulting from an appeal filed after the sixty-day period described in subsection (2)(e) of this section is effective on the date the rate appeal is received by the department.

     (i) Any rate decrease resulting from an appeal is effective on the date specified in the appeal decision letter.

     (j) Any rate change that ((MAA)) the department grants that is the result of fraudulent practices on the part of the contractor/provider as described under RCW 74.09.210 is exempt from the appeal provisions in this chapter.

     (3) The second level of appeal. When the contractor/provider disagrees with a rate review decision, it may file a request for a dispute conference with ((MAA)) the department. For this section "dispute conference" means an informal administrative hearing for the purpose of resolving contractor/provider disagreements with a department action as described under subsection (1) of this section, and not agreed upon at the first level of appeal. The dispute conference is not governed by the Administrative Procedure Act, chapter 34.05 RCW.

     (a) If a contractor/provider files a request for a dispute conference, it must submit the request to ((MAA)) the department within thirty calendar days after the contractor/provider receives the rate review decision. ((MAA)) The department does not consider dispute conference requests submitted after the thirty-day period for the first level decision.

     (b) ((MAA)) The department conducts the dispute conference within ninety calendar days of receiving the request.

     (c) A department-appointed conference chairperson issues the final decision within thirty calendar days of the conference. Extensions of time for extenuating circumstances may be granted if all parties agree.

     (d) Any rate increase or decrease resulting from a dispute conference decision is effective on the date specified in the dispute conference decision.

     (e) The dispute conference is the final level of administrative appeal within the department and precede judicial action.

     (4) ((MAA)) The department considers that a contractor/provider who fails to attempt to resolve disputed rates as provided in this section has abandoned the dispute.

[Statutory Authority: RCW 74.08.090 and 74.09.730. 99-16-070, § 388-502-0220, filed 8/2/99, effective 9/2/99. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-502-0220, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-043.]

     "Acquisition cost" means the cost of an item excluding shipping, handling, and any applicable taxes.

     "Acute care" means care provided for clients who are not medically stable. These clients require frequent monitoring by a health care professional in order to maintain their health status. See also WAC 246-335-015.

     "Acute physical medicine and rehabilitation (PM&R)" means a comprehensive inpatient and rehabilitative program coordinated by a multidisciplinary team at ((an MAA-approved)) a department-approved rehabilitation facility. The program provides twenty-four hour specialized nursing services and an intense level of specialized therapy (speech, physical, and occupational) for a diagnostic category for which the client shows significant potential for functional improvement (see WAC 388-550-2501).

     "Add-on procedure(s)" means secondary procedure(s) that are performed in addition to another procedure.

     "Admitting diagnosis" means the medical condition responsible for a hospital admission, as defined by ICD-9-M diagnostic code.

     "Advanced registered nurse practitioner (ARNP)" means a registered nurse prepared in a formal educational program to assume an expanded health services provider role in accordance with WAC 246-840-300 and 246-840-305.

     "Aging and disability services administration (ADSA)" means the administration that administers directly or contracts for long-term care services, including but not limited to nursing facility care and home and community services. See WAC 388-71-0202.

     "Allowed charges" means the maximum amount reimbursed for any procedure that is allowed by ((MAA)) the department.

     "Anesthesia technical advisory group (ATAG)" means an advisory group representing anesthesiologists who are affected by the implementation of the anesthesiology fee schedule.

     "Bariatric surgery" means any surgical procedure, whether open or by laparoscope, which reduces the size of the stomach with or without bypassing a portion of the small intestine and whose primary purpose is the reduction of body weight in an obese individual.

     "Base anesthesia units (BAU)" means a number of anesthesia units assigned to a surgical procedure that includes the usual pre-operative, intra-operative, and post-operative visits. This includes the administration of fluids and/or blood incident to the anesthesia care, and interpretation of noninvasive monitoring by the anesthesiologist.

     "Bundled services" means services integral to the major procedure that are included in the fee for the major procedure. Bundled services are not reimbursed separately.

     "Bundled supplies" means supplies which are considered to be included in the practice expense RVU of the medical or surgical service of which they are an integral part.

     "By report (BR)" means a method of reimbursement in which ((MAA)) the department determines the amount it will pay for a service that is not included in ((MAA's)) the department's published fee schedules. ((MAA)) The department may request the provider to submit a "report" describing the nature, extent, time, effort, and/or equipment necessary to deliver the service.

     "Call" means a face-to-face encounter between the client and the provider resulting in the provision of services to the client.

     "Cast material maximum allowable fee" means a reimbursement amount based on the average cost among suppliers for one roll of cast material.

     "Centers for Medicare and Medicaid Services (CMS)" means the agency within the federal Department of Health and Human Services (DHHS) with oversight responsibility for medicare and medicaid programs.

     "Certified registered nurse anesthetist (CRNA)" means an advanced registered nurse practitioner (ARNP) with formal training in anesthesia who meets all state and national criteria for certification. The American Association of Nurse Anesthetists specifies the National Certification and scope of practice.

     "Children's health insurance plan (CHIP)," see chapter 388-542 WAC.

     "Clinical Laboratory Improvement Amendment (CLIA)" means regulations from the U.S. Department of Health and Human Services that require all laboratory testing sites to have either a CLIA registration or a CLIA certificate of waiver in order to legally perform testing anywhere in the U.S.

     "Conversion factors" means dollar amounts ((MAA)) the department uses to calculate the maximum allowable fee for physician-related services.

     "Covered service" means a service that is within the scope of the eligible client's medical care program, subject to the limitations in this chapter and other published WAC.

     "CPT," see "current procedural terminology."

     "Critical care services" means physician services for the care of critically ill or injured clients. A critical illness or injury acutely impairs one or more vital organ systems such that the client's survival is jeopardized. Critical care is given in a critical care area, such as the coronary care unit, intensive care unit, respiratory care unit, or the emergency care facility.

     "Current procedural terminology (CPT)" means a systematic listing of descriptive terms and identifying codes for reporting medical services, procedures, and interventions performed by physicians and other practitioners who provide physician-related services. CPT is copyrighted and published annually by the American Medical Association (AMA).

     "Diagnosis code" means a set of numeric or alphanumeric characters assigned by the ICD-9-CM, or successor document, as a shorthand symbol to represent the nature of a disease.

     "Emergency medical condition(s)" means a medical condition(s) that manifests itself by acute symptoms of sufficient severity so that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

     "Emergency services" means medical services required by and provided to a patient experiencing an emergency medical condition.

     "Estimated acquisition cost (EAC)" means the department's best estimate of the price providers generally and currently pay for drugs and supplies.

     "Evaluation and management (E&M) codes" means procedure codes which categorize physician services by type of service, place of service, and patient status.

     "Expedited prior authorization" means the process of obtaining authorization that must be used for selected services, in which providers use a set of numeric codes to indicate to ((MAA)) the department which acceptable indications, conditions, diagnoses, and/or criteria are applicable to a particular request for services.

     "Experimental" means a term to describe a procedure, or course of treatment, which lacks sufficient scientific evidence of safety and effectiveness. See WAC 388-531-0550. A service is not "experimental" if the service:

     (1) Is generally accepted by the medical profession as effective and appropriate; and

     (2) Has been approved by the FDA or other requisite government body, if such approval is required.

     "Fee-for-service" means the general payment method ((MAA)) the department uses to reimburse providers for covered medical services provided to medical assistance clients when those services are not covered under ((MAA's)) the department's healthy options program or children's health insurance program (CHIP) programs.

     "Flat fee" means the maximum allowable fee established by ((MAA)) the department for a service or item that does not have a relative value unit (RVU) or has an RVU that is not appropriate.

     "Geographic practice cost index (GPCI)" as defined by medicare, means a medicare adjustment factor that includes local geographic area estimates of how hard the provider has to work (work effort), what the practice expenses are, and what malpractice costs are. The GPCI reflects one-fourth the difference between the area average and the national average.

     "Global surgery reimbursement," see WAC 388-531-1700.

     "HCPCS Level II" means a coding system established by CMS (formerly known as the Health Care Financing Administration) to define services and procedures not included in CPT.

     "Health care financing administration common procedure coding system (HCPCS)" means the name used for the Centers for Medicare and Medicaid Services (formerly known as the Health Care Financing Administration) codes made up of CPT and HCPCS level II codes.

     "Health care team" means a group of health care providers involved in the care of a client.

     "Hospice" means a medically directed, interdisciplinary program of palliative services which is provided under arrangement with a Title XVIII Washington licensed and certified Washington state hospice for terminally ill clients and the clients' families.

     "ICD-9-CM," see "International Classification of Diseases, 9th Revision, Clinical Modification."

     "Informed consent" means that an individual consents to a procedure after the provider who obtained a properly completed consent form has done all of the following:

     (1) Disclosed and discussed the client's diagnosis; and

     (2) Offered the client an opportunity to ask questions about the procedure and to request information in writing; and

     (3) Given the client a copy of the consent form; and

     (4) Communicated effectively using any language interpretation or special communication device necessary per 42 C.F.R. Chapter IV 441.257; and

     (5) Given the client oral information about all of the following:

     (a) The client's right to not obtain the procedure, including potential risks, benefits, and the consequences of not obtaining the procedure; and

     (b) Alternatives to the procedure including potential risks, benefits, and consequences; and

     (c) The procedure itself, including potential risks, benefits, and consequences.

     "Inpatient hospital admission" means an admission to a hospital that is limited to medically necessary care based on an evaluation of the client using objective clinical indicators, assessment, monitoring, and therapeutic service required to best manage the client's illness or injury, and that is documented in the client's medical record.

     "International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)" means the systematic listing that transforms verbal descriptions of diseases, injuries, conditions, and procedures into numerical or alphanumerical designations (coding).

     "Investigational" means a term to describe a procedure, or course of treatment, which lacks sufficient scientific evidence of benefit for a particular condition. A service is not "investigational" if the service:

     (1) Is generally accepted by the medical professional as effective and appropriate for the condition in question; or

     (2) Is supported by an overall balance of objective scientific evidence, in which the potential risks and potential benefits are examined, demonstrating the proposed service to be of greater overall benefit to the client in the particular circumstance than another, generally available service.

     "Life support" means mechanical systems, such as ventilators or heart-lung respirators, which are used to supplement or take the place of the normal autonomic functions of a living person.

     "Limitation extension" means a process for requesting and approving reimbursement for covered services whose proposed quantity, frequency, or intensity exceeds that which ((MAA)) the department routinely reimburses. Limitation extensions require prior authorization.

     "Maximum allowable fee" means the maximum dollar amount that ((MAA)) the department will reimburse a provider for specific services, supplies, and equipment.

     "Medically necessary," see WAC 388-500-0005.

     "Medicare physician fee schedule data base (MPFSDB)" means the official HCFA publication of the medicare policies and RVUs for the RBRVS reimbursement program.

     "Medicare program fee schedule for physician services (MPFSPS)" means the official HCFA publication of the medicare fees for physician services.

     "Medicare clinical diagnostic laboratory fee schedule" means the fee schedule used by medicare to reimburse for clinical diagnostic laboratory procedures in the state of Washington.

     "Mentally incompetent" means a client who has been declared mentally incompetent by a federal, state, or local court.

     "Modifier" means a two-digit alphabetic and/or numeric identifier that is added to the procedure code to indicate the type of service performed. The modifier provides the means by which the reporting physician can describe or indicate that a performed service or procedure has been altered by some specific circumstance but not changed in its definition or code. The modifier can affect payment or be used for information only. Modifiers are listed in fee schedules.

     "Outpatient" means a client who is receiving medical services in other than an inpatient hospital setting.

     "Peer-reviewed medical literature" means medical literature published in professional journals that submit articles for review by experts who are not part of the editorial staff. It does not include publications or supplements to publications primarily intended as marketing material for pharmaceutical, medical supplies, medical devices, health service providers, or insurance carriers.

     "Physician care plan" means a written plan of medically necessary treatment that is established by and periodically reviewed and signed by a physician. The plan describes the medically necessary services to be provided by a home health agency, a hospice agency, or a nursing facility.

     "Physician standby" means physician attendance without direct face-to-face client contact and which does not involve provision of care or services.

     "Physician's current procedural terminology," see "CPT, current procedural terminology."

     "PM&R," see acute physical medicine and rehabilitation.

     "Podiatric service" means the diagnosis and medical, surgical, mechanical, manipulative, and electrical treatments of ailments of the foot and ankle.

     "Pound indicator (#)" means a symbol (#) indicating a CPT procedure code listed in ((MAA)) the department's fee schedules that is not routinely covered.

     "Preventive" means medical practices that include counseling, anticipatory guidance, risk factor reduction interventions, and the ordering of appropriate laboratory and diagnostic procedures intended to help a client avoid or reduce the risk or incidence of illness or injury.

     "Prior authorization" means a process by which clients or providers must request and receive ((MAA)) the department approval for certain medical services, equipment, or supplies, based on medical necessity, before the services are provided to clients, as a precondition for provider reimbursement. Expedited prior authorization and limitation extension are forms of prior authorization.

     "Professional component" means the part of a procedure or service that relies on the provider's professional skill or training, or the part of that reimbursement that recognizes the provider's cognitive skill.

     "Prognosis" means the probable outcome of a client's illness, including the likelihood of improvement or deterioration in the severity of the illness, the likelihood for recurrence, and the client's probable life span as a result of the illness.

     "Prolonged services" means face-to-face client services furnished by a provider, either in the inpatient or outpatient setting, which involve time beyond what is usual for such services. The time counted toward payment for prolonged E&M services includes only face-to-face contact between the provider and the client, even if the service was not continuous.

     "Provider," see WAC 388-500-0005.

     "Radioallergosorbent test" or "RAST" means a blood test for specific allergies.

     "RBRVS," see resource based relative value scale.

     "RVU," see relative value unit.

     "Reimbursement" means payment to a provider or other ((MAA-approved)) department-approved entity who bills according to the provisions in WAC 388-502-0100.

     "Reimbursement steering committee (RSC)" means an interagency work group that establishes and maintains RBRVS physician fee schedules and other payment and purchasing systems utilized by the health care authority, ((MAA)) the department, and department of labor and industries.

     "Relative value guide (RVG)" means a system used by the American Society of Anesthesiologists for determining base anesthesia units (BAUs).

     "Relative value unit (RVU)" means a unit which is based on the resources required to perform an individual service or intervention.

     "Resource based relative value scale (RBRVS)" means a scale that measures the relative value of a medical service or intervention, based on the amount of physician resources involved.

     "RBRVS RVU" means a measure of the resources required to perform an individual service or intervention. It is set by medicare based on three components - physician work, practice cost, and malpractice expense. Practice cost varies depending on the place of service.

     "RSC RVU" means a unit established by the RSC for a procedure that does not have an established RBRVS RVU or has an RBRVS RVU deemed by the RSC as not appropriate for the service.

     "Stat laboratory charges" means charges by a laboratory for performing tests immediately. "Stat" is an abbreviation for the Latin word "statim," meaning immediately.

     "Sterile tray" means a tray containing instruments and supplies needed for certain surgical procedures normally done in an office setting. For reimbursement purposes, tray components are considered by HCFA to be nonroutine and reimbursed separately.

     "Technical advisory group (TAG)" means an advisory group with representatives from professional organizations whose members are affected by implementation of RBRVS physician fee schedules and other payment and purchasing systems utilized by the health care authority, ((MAA)) the department, and department of labor and industries.

     "Technical component" means the part of a procedure or service that relates to the equipment set-up and technician's time, or the part of the procedure and service reimbursement that recognizes the equipment cost and technician time.

[Statutory Authority: RCW 74.08.090 and 74.09.500. 04-20-059, § 388-531-0050, filed 10/1/04, effective 11/1/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. 03-19-081, § 388-531-0050, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090. 03-06-049, § 388-531-0050, filed 2/28/03, effective 3/31/03. Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0050, filed 12/6/00, effective 1/6/01.]

     (a) Acupuncture, massage, or massage therapy;

     (b) Any service specifically excluded by statute;

     (c) Care, testing, or treatment of infertility, frigidity, or impotency. This includes procedures for donor ovum, sperm, womb, and reversal of vasectomy or tubal ligation;

     (d) Cosmetic treatment or surgery, except for medically necessary reconstructive surgery to correct defects attributable to trauma, birth defect, or illness;

     (e) Experimental or investigational services, procedures, treatments, devices, drugs, or application of associated services, except when the individual factors of an individual client's condition justify a determination of medical necessity under WAC 388-501-0165;

     (f) Hair transplantation;

     (g) Marital counseling or sex therapy;

     (h) More costly services when ((MAA)) the department determines that less costly, equally effective services are available;

     (i) Vision-related services listed as noncovered in chapter 388-544 WAC;

     (j) Payment for body parts, including organs, tissues, bones and blood, except as allowed in WAC 388-531-1750;

     (k) Physician-supplied medication, except those drugs administered by the physician in the physician's office;

     (l) Physical examinations or routine checkups, except as provided in WAC 388-531-0100;

     (m) Routine foot care. This does not include clients who have a medical condition that affects the feet, such as diabetes or arteriosclerosis obliterans. Routine foot care includes, but is not limited to:

     (i) Treatment of mycotic disease;

     (ii) Removal of warts, corns, or calluses;

     (iii) Trimming of nails and other hygiene care; or

     (iv) Treatment of flat feet;

     (n) Except as provided in WAC 388-531-1600, weight reduction and control services, procedures, treatments, devices, drugs, products, gym memberships, equipment for the purpose of weight reduction, or the application of associated services.

     (o) Nonmedical equipment; and

     (p) Nonemergent admissions and associated services to out-of-state hospitals or noncontracted hospitals in contract areas.

     (2) ((MAA)) The department covers excluded services listed in (1) of this subsection if those services are mandated under and provided to a client who is eligible for one of the following:

     (a) The EPSDT program;

     (b) A medicaid program for qualified medicare beneficiaries (QMBs); or

     (c) A waiver program.

[Statutory Authority: RCW 74.08.090, 74.09.520. 05-12-022, § 388-531-0150, filed 5/20/05, effective 6/20/05; 01-01-012, § 388-531-0150, filed 12/6/00, effective 1/6/01.]

     (2) The EPA process is designed to eliminate the need for telephone prior authorization for selected admissions and procedures.

     (a) The provider must create an authorization number using the process explained in ((MAA's)) the department's physician-related billing instructions.

     (b) Upon request, the provider must provide supporting clinical documentation to ((MAA)) the department showing how the authorization number was created.

     (c) Selected nonemergent admissions to contract hospitals require EPA. These are identified in ((MAA)) the department billing instructions.

     (d) Procedures requiring expedited prior authorization include, but are not limited to, the following:

     (i) Bladder repair;

     (ii) Hysterectomy for clients age forty-five and younger, except with a diagnosis of cancer(s) of the female reproductive system;

     (iii) Outpatient magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA);

     (iv) Reduction mammoplasties/mastectomy for geynecomastia; and

     (v) Strabismus surgery for clients eighteen years of age and older.

     (3) ((MAA)) The department evaluates new technologies under the procedures in WAC 388-531-0550. These require prior authorization.

     (4) Prior authorization is required for the following:

     (a) Abdominoplasty;

     (b) All inpatient hospital stays for acute physical medicine and rehabilitation (PM&R);

     (c) Cochlear implants, which also:

     (i) For coverage, must be performed in an ambulatory surgery center (ASC) or an inpatient or outpatient hospital facility; and

     (ii) For reimbursement, must have the invoice attached to the claim;

     (d) Diagnosis and treatment of eating disorders for clients twenty-one years of age and older;

     (e) Osteopathic manipulative therapy in excess of ((MAA's)) the department's published limits;

     (f) Panniculectomy;

     (g) Bariatric surgery (see WAC 388-531-1600); and

     (h) Vagus nerve stimulator insertion, which also:

     (i) For coverage, must be performed in an inpatient or outpatient hospital facility; and

     (ii) For reimbursement, must have the invoice attached to the claim.

     (5) ((MAA)) The department may require a second opinion and/or consultation before authorizing any elective surgical procedure.

     (6) Children six year of age and younger do not require authorization for hospitalization.

[Statutory Authority: RCW 74.08.090, 74.09.520. 05-12-022, § 388-531-0200, filed 5/20/05, effective 6/20/05; 01-01-012, § 388-531-0200, filed 12/6/00, effective 1/6/01.]

     (1) ((MAA)) The department reimburses providers for covered anesthesia services performed by:

     (a) Anesthesiologists;

     (b) Certified registered nurse anesthetists (CRNAs);

     (c) Oral surgeons with a special agreement with ((MAA)) the department to provide anesthesia services; and

     (d) Other providers who have a special agreement with ((MAA)) the department to provide anesthesia services.

     (2) ((MAA)) The department covers and reimburses anesthesia services for children and noncooperative clients in those situations where the medically necessary procedure cannot be performed if the client is not anesthetized. A statement of the client-specific reasons why the procedure could not be performed without specific anesthesia services must be kept in the client's medical record. Examples of such procedures include:

     (a) Computerized tomography (CT);

     (b) Dental procedures;

     (c) Electroconvulsive therapy; and

     (d) Magnetic resonance imaging (MRI).

     (3) ((MAA)) The department covers anesthesia services provided for any of the following:

     (a) Dental restorations and/or extractions:

     (b) Maternity per subsection (9) of this section. See WAC 388-531-1550 for information about sterilization/hysterectomy anesthesia;

     (c) Pain management per subsection (5) of this section;

     (d) Radiological services as listed in WAC 388-531-1450; and

     (e) Surgical procedures.

     (4) For each client, the anesthesiologist provider must do all of the following:

     (a) Perform a pre-anesthetic examination and evaluation;

     (b) Prescribe the anesthesia plan;

     (c) Personally participate in the most demanding aspects of the anesthesia plan, including, if applicable, induction and emergence;

     (d) Ensure that any procedures in the anesthesia plan that the provider does not perform, are performed by a qualified individual as defined in the program operating instructions;

     (e) At frequent intervals, monitor the course of anesthesia during administration;

     (f) Remain physically present and available for immediate diagnosis and treatment of emergencies; and

     (g) Provide indicated post anesthesia care.

     (5) ((MAA)) The department does not allow the anaesthesiologist provider to:

     (a) Direct more than four anesthesia services concurrently; and

     (b) Perform any other services while directing the single or concurrent services, other than attending to medical emergencies and other limited services as allowed by medicare instructions.

     (6) ((MAA)) The department requires the anesthesiologist provider to document in the client's medical record that the medical direction requirements were met.

     (7) General anesthesia:

     (a) When a provider performs multiple operative procedures for the same client at the same time, ((MAA)) the department reimburses the base anesthesia units (BAU) for the major procedure only.

     (b) ((MAA)) The department does not reimburse the attending surgeon for anesthesia services.

     (c) When more than one anesthesia provider is present on a case, ((MAA)) the department reimburses as follows:

     (i) The supervisory anesthesiologist and certified registered nurse anesthetist (CRNA) each receive fifty percent of the allowed amount.

     (ii) For anesthesia provided by a team, ((MAA)) the department limits reimbursement to one hundred percent of the total allowed reimbursement for the service.

     (8) Pain management:

     (a) ((MAA)) The department pays CRNAs or anesthesiologists for pain management services.

     (b) ((MAA)) The department allows two postoperative or pain management epidurals per client, per hospital stay plus the two associated E&M fees for pain management.

     (9) Maternity anesthesia:

     (a) To determine total time for obstetric epidural anesthesia during normal labor and delivery and c-sections, time begins with insertion and ends with removal for a maximum of six hours. "Delivery" includes labor for single or multiple births, and/or cesarean section delivery.

     (b) ((MAA)) The department does not apply the six-hour limit for anesthesia to procedures performed as a result of post-delivery complications.

     (c) See WAC 388-531-1550 for information on anesthesia services during a delivery with sterilization.

     (d) See chapter 388-533 WAC for more information about maternity-related services.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0300, filed 12/6/00, effective 1/6/01.]

     (2) ((MAA)) The department calculates payment for anesthesia by adding the BAU to the time units and multiplying that sum by the conversion factor. The formula used in the calculation is: (BAU x fifteen) + time) x (conversion factor divided by fifteen) = reimbursement.

     (3) ((MAA)) The department obtains BAU values from the relative value guide (RVG), and updates them annually. ((MAA)) The department and/or the anesthesia technical advisory group (ATAG) members establish the base units for procedures for which anesthesia is appropriate but do not have BAUs established by RVSP and are not defined as add-on.

     (4) ((MAA)) The department determines a budget neutral anesthesia conversion factor by:

     (a) Determining the BAUs, time units, and expenditures for a base period for the provided procedure. Then,

     (b) Adding the latest BAU RVSP to the time units for the base period to obtain an estimate of the new time unit for the procedure. Then,

     (c) Multiplying the time units obtained in (b) of this subsection for the new period by a conversion factor to obtain estimated expenditures. Then,

     (d) Comparing the expenditures obtained in (c) of this subsection with base period expenditure levels obtained in (a) of this subsection. Then,

     (e) Adjusting the dollar amount for the anesthesia conversion factor and the projected time units at the new BAUs equals the allocated amount determined in (a) of this subsection.

     (5) ((MAA)) The department calculates anesthesia time units as follows:

     (a) One minute equals one unit.

     (b) The total time is calculated to the next whole minute.

     (c) Anesthesia time begins when the anesthesiologist, surgeon, or CRNA begins physically preparing the client for the induction of anesthesia; this must take place in the operating room or its equivalent. When there is a break in continuous anesthesia care, blocks of time may be added together as long as there is continuous monitoring. Examples of this include, but are not limited to, the following:

     (i) The time a client spends in an anesthesia induction room; or

     (ii) The time a client spends under the care of an operating room nurse during a surgical procedure.

     (d) Anesthesia time ends when the anesthesiologist, surgeon, or CRNA is no longer in constant attendance (i.e., when the client can be safely placed under post-operative supervision).

     (6) ((MAA)) The department changes anesthesia conversion factors if the legislature grants a vendor rate increase, or other increase, and if the effective date of that increase is not the same as ((MAA's)) the department's annual update.

     (7) If the legislatively authorized vendor rate increase or other increase becomes effective at the same time as ((MAA's)) the department's annual update, ((MAA)) the department applies the increase after calculating the budget-neutral conversion factor.

     (8) When more than one surgical procedure is performed at the same operative session, ((MAA)) the department uses the BAU of the major procedure to determine anesthesia allowed charges. ((MAA)) The department reimburses for add-on procedures as defined by CPT only for the time spent on the add-on procedure that is in addition to the time spent on the major procedure.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0350, filed 12/6/00, effective 1/6/01.]

     (a) The attending physician who assumes responsibility for the care of a client during a life-threatening episode;

     (b) More than one physician if the services provided involve multiple organ systems; or

     (c) Only one physician for services provided in the emergency room.

     (2) ((MAA)) The department reimburses preoperative and postoperative critical care in addition to a global surgical package when all the following apply:

     (a) The client is critically ill and the physician is engaged in work directly related to the individual client's care, whether that time is spent at the immediate bedside or elsewhere on the floor;

     (b) The critical injury or illness acutely impairs one or more vital organ systems such that the client's survival is jeopardized;

     (c) The critical care is unrelated to the specific anatomic injury or general surgical procedure performed; and

     (d) The provider uses any necessary, appropriate modifier when billing ((MAA)) the department.

     (3) ((MAA)) The department limits payment for critical care services to a maximum of three hours per day, per client.

     (4) ((MAA)) The department does not pay separately for certain services performed during a critical care period when the services are provided on a per hour basis. These services include, but are not limited to, the following:

     (a) Analysis of information data stored in computers (e.g., ECG, blood pressure, hematologic data);

     (b) Blood draw for a specimen;

     (c) Blood gases;

     (d) Cardiac output measurement;

     (e) Chest X rays;

     (f) Gastric intubation;

     (g) Pulse oximetry;

     (h) Temporary transcutaneous pacing;

     (i) Vascular access procedures; and

     (j) Ventilator management.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0450, filed 12/6/00, effective 1/6/01.]

     (2) ((MAA)) The department reimburses emergency physician services only when provided by physicians assigned to the hospital emergency department or the physicians on call to cover the hospital emergency department.

     (3) ((MAA)) The department pays a provider who is called back to the emergency room at a different time on the same day to attend a return visit the same client. When this results in multiple claims on the same day, the time of each encounter must be clearly indicated on the claim.

     (4) ((MAA)) The department does not pay emergency room physicians for hospital admission charges or additional service charges.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0500, filed 12/6/00, effective 1/6/01.]

     (2) The determination of whether a service is experimental and/or investigational is subject to a case-by-case review under the provisions of WAC 388-501-0165 which relate to medical necessity. ((MAA)) The department also considers the following:

     (a) Evidence in peer-reviewed medical literature, as defined in WAC 388-531-0050, and preclinical and clinical data reported to the National Institute of Health and/or the National Cancer Institute, concerning the probability of the service maintaining or significantly improving the enrollee's length or quality of life, or ability to function, and whether the benefits of the service or treatment are outweighed by the risks of death or serious complications;

     (b) Whether evidence indicates the service or treatment is more likely than not to be as beneficial as existing conventional treatment alternatives for the treatment of the condition in question;

     (c) Whether the service or treatment is generally used or generally accepted for treatment of the condition in the United States;

     (d) Whether the service or treatment is under continuing scientific testing and research;

     (e) Whether the service or treatment shows a demonstrable benefit for the condition;

     (f) Whether the service or treatment is safe and efficacious;

     (g) Whether the service or treatment will result in greater benefits for the condition than another generally available service; and

     (h) If approval is required by a regulating agency, such as the Food and Drug Administration, whether such approval has been given before the date of service.

     (3) ((MAA)) The department applies consistently across clients with the same medical condition and health status, the criteria to determine whether a service is experimental. A service or treatment that is not experimental for one client with a particular medical condition is not determined to be experimental for another enrollee with the same medical condition and health status. A service that is experimental for one client with a particular medical condition is not necessarily experimental for another, and subsequent individual determinations must consider any new or additional evidence not considered in prior determinations.

     (4) ((MAA)) The department does not determine a service or treatment to be experimental or investigational solely because it is under clinical investigation when there is sufficient evidence in peer-reviewed medical literature to draw conclusions, and the evidence indicates the service or treatment will probably be of greater overall benefit to the client in question than another generally available service.

     (5) All determinations that a proposed service or treatment is "experimental" or "investigation" are subject to the review and approval of a physician who is:

     (a) Licensed under chapter 18.57 RCW or an osteopath licensed under chapter 18.71 RCW;

     (b) Designated by ((MAA's)) the department's medical director to issue such approvals; and

     (c) Available to consult with the client's treating physician by telephone.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0550, filed 12/6/00, effective 1/6/01.]

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0600, filed 12/6/00, effective 1/6/01.]

     (1) All transplant procedures specified in WAC 388-550-1900;

     (2) Chronic pain management services, including outpatient evaluation and inpatient treatment, as described under WAC 388-550-2400. See also WAC 388-531-0700;

     (3) Sleep studies including but not limited to polysomnograms for clients one year of age and older. ((MAA)) The department allows sleep studies only in outpatient hospital settings as described under WAC 388-550-6350. See also WAC 388-531-1500; and

     (4) Diabetes education, in a DOH-approved facility, per WAC 388-550-6300.

[Statutory Authority: RCW 74.08.090, 74.09.520. 05-12-022, § 388-531-0650, filed 5/20/05, effective 6/20/05; 01-01-012, § 388-531-0650, filed 12/6/00, effective 1/6/01.]

     (2) A client qualifies for inpatient chronic pain management services when all of the following apply:

     (a) The client has had chronic pain for at least three months, that has not improved with conservative treatment, including tests and therapies;

     (b) At least six months have passed since a previous surgical procedure was done in relation to the pain problem; and

     (c) Clients with active substance abuse must have completed a detoxification program, if appropriate, and must be free from drugs or alcohol for six months.

     (3) For chronic pain management, ((MAA)) the department limits coverage to only one inpatient hospital stay per client's lifetime, up to a maximum of twenty-one days.

     (4) ((MAA)) The department reimburses for only the chronic pain management services and procedures that are listed in the fee schedule.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0700, filed 12/6/00, effective 1/6/01.]

     (2) ((MAA)) The department reimburses for only one inpatient hospital call per client, per day for the same or related diagnoses. If a call is included in the global surgery reimbursement, ((MAA)) the department does not reimburse separately.

     (3) ((MAA)) The department reimburses a hospital admission related to a planned surgery through the global fee for surgery.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0750, filed 12/6/00, effective 1/6/01.]

     (a) The provider is certified according to Title XVII of the Social Security Act (medicare), if required; and

     (b) The provider has a clinical laboratory improvement amendment (CLIA) certificate and identification number.

     (2) ((MAA)) The department includes a handling, packaging, and mailing fee in the reimbursement for lab tests and does not reimburse these separately.

     (3) ((MAA)) The department reimburses only one blood drawing fee per client, per day. ((MAA)) The department allows additional reimbursement for an independent laboratory when it goes to a nursing facility or a private home to obtain a specimen.

     (4) ((MAA)) The department reimburses only one catheterization for collection of a urine specimen per client, per day.

     (5) ((MAA)) The department reimburses automated multichannel tests done alone or as a group, as follows:

     (a) The provider must bill a panel if all individual tests are performed. If not all tests are performed, the provider must bill individual tests.

     (b) If the provider bills one automated multichannel test, ((MAA)) the department reimburses the test at the individual procedure code rate, or the internal code maximum allowable fee, whichever is lower.

     (c) Tests may be performed in a facility that owns or leases automated multichannel testing equipment. The facility may be any of the following:

     (i) A clinic;

     (ii) A hospital laboratory;

     (iii) An independent laboratory; or

     (iv) A physician's office.

     (6) ((MAA)) The department allows a STAT fee in addition to the maximum allowable fee when a laboratory procedure is performed STAT.

     (a) ((MAA)) The department reimburses STAT charges for only those procedures identified by the clinical laboratory advisory council as appropriate to be performed STAT.

     (b) Tests generated in the emergency room do not automatically justify a STAT order, the physician must specifically order the tests as STAT.

     (c) Refer to the fee schedule for a list of STAT procedures.

     (7) ((MAA)) The department reimburses for drug screen charges only when medically necessary and when ordered by a physician as part of a total medical evaluation.

     (8) ((MAA)) The department does not reimburse for drug screens for clients in the division of alcohol and substance abuse (DASA)-contracted methadone treatment programs. These are reimbursed through a contract issued by DASA.

     (9) ((MAA)) The department does not cover for drug screens to monitor any of the following:

     (a) Program compliance in either a residential or outpatient drug or alcohol treatment program;

     (b) Drug or alcohol abuse by a client when the screen is performed by a provider in private practice setting; or

     (c) Suspected drug use by clients in a residential setting, such as a group home.

     (10) ((MAA)) The department may require a drug or alcohol screen in order to determine a client's suitability for a specific test.

     (11) An independent laboratory must bill ((MAA)) the department directly. ((MAA)) The department does not reimburse a medical practitioner for services referred to or performed by an independent laboratory.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0800, filed 12/6/00, effective 1/6/01.]

     (2) ((MAA)) The department updates budget-neutral fees each July by:

     (a) Determining the units of service and expenditures for a base period. Then,

     (b) Determining in total the ratio of current ((MAA)) department fees to existing medicare fees. Then,

     (c) Determining new ((MAA)) department fees by adjusting the new medicare fee by the ratio. Then,

     (d) Multiplying the units of service by the new ((MAA)) department fee to obtain total estimated expenditures. Then,

     (e) Comparing the expenditures in subsection (14)(d) of this section to the base period expenditures. Then,

     (f) Adjusting the new ratio until estimated expenditures equals the base period amount.

     (3) ((MAA)) The department calculates maximum allowable fees (MAF) by:

     (a) Calculating fees using methodology described in subsection (2) of this section for procedure codes that have an applicable medicare clinical diagnostic laboratory fee (MCDLF).

     (b) Establishing RSC fees for procedure codes that have no applicable MCDLF.

     (c) Establishing maximum allowable fees, or "flat fees" for procedure codes that have no applicable MCDLF or RSC fees. ((MAA)) The department updates flat fee reimbursement only when authorized by the legislature.

     (d) ((MAA)) The department reimbursement for clinical laboratory diagnostic procedures does not exceed the regional MCDLF schedule.

     (4) ((MAA)) The department increases fees if the legislature grants a vendor rate increase or other increase. If the legislatively authorized increase becomes effective at the same time as ((MAA's)) the department's annual update, ((MAA)) the department applies the increase after calculating budget-neutral fees.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0850, filed 12/6/00, effective 1/6/01.]

     (2) NICU services include, but are not limited to, any of the following:

     (a) Patient management;

     (b) Monitoring and treatment of the neonate, including nutritional, metabolic and hematologic maintenance;

     (c) Parent counseling; and

     (d) Personal direct supervision by the health care team of activities required for diagnosis, treatment, and supportive care of the patient.

     (3) Payment for NICU care begins with the date of admission to the NICU.

     (4) ((MAA)) The department reimburses a provider for only one NICU service per client, per day.

     (5) A provider may bill for NICU services in addition to prolonged services and newborn resuscitation when the provider is present at the delivery.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0900, filed 12/6/00, effective 1/6/01.]

     (a) Two calls per month for routine medical conditions for a client residing in a nursing facility; and.

     (b) One call per noninstitutionalized client, per day, for an individual physician, except for valid call-backs to the emergency room per WAC 388-531-0500.

     (2) The provider must provide justification based on medical necessity at the time of billing for visits in excess of subsection (l) of this section.

     (3) See physician billing instructions for procedures that are included in the office call and cannot be billed separately.

     (4) Using selected diagnosis codes, ((MAA)) the department reimburses the provider at the appropriate level of physician office call for history and physical procedures in conjunction with dental surgery services performed in an outpatient setting.

     (5) ((MAA)) The department may reimburse providers for injection procedures and/or injectable drug products only when:

     (a) The injectable drug is administered during an office visit; and

     (b) The injectable drug used is from office stock and purchased by the provider from a pharmacist or drug manufacturer as described in WAC 388-530-1200.

     (6) ((MAA)) The department does not reimburse a prescribing provider for a drug when a pharmacist dispenses the drug.

     (7) ((MAA)) The department does not reimburse the prescribing provider for an immunization when the immunization material is received from the department of health; ((MAA)) the department does reimburse an administrative fee. If the immunization is given in a health department and is the only service provided, ((MAA)) the department reimburses a minimum E&M service.

     (8) ((MAA)) The department reimburses immunizations at estimated acquisition costs (EAC) when the immunizations are not part of the vaccine for children program. ((MAA)) The department reimburses a separate administration fee for these immunizations. Covered immunizations are listed in the fee schedule.

     (9) ((MAA)) The department reimburses therapeutic and diagnostic injections subject to certain limitations as follows:

     (a) ((MAA)) The department does not pay separately for the administration of intra-arterial and intravenous therapeutic or diagnostic injections provided in conjunction with intravenous infusion therapy services. ((MAA)) The department does pay separately for the administration of these injections when they are provided on the same day as an E&M service. ((MAA)) The department does not pay separately an administrative fee for injectables when both E&M and infusion therapy services are provided on the same day. ((MAA)) The department reimburses separately for the drug(s).

     (b) ((MAA)) The department does not pay separately for subcutaneous or intramuscular administration of antibiotic injections provided on the same day as an E&M service. If the injection is the only service provided, ((MAA)) the department pays an administrative fee. ((MAA)) The department reimburses separately for the drug.

     (c) ((MAA)) The department reimburses injectable drugs at acquisition cost. The provider must document the name, strength, and dosage of the drug and retain that information in the client's file. The provider must provide an invoice when requested by ((MAA)) the department. This subsection does not apply to drugs used for chemotherapy; see subsection (11) in this section for chemotherapy drugs.

     (d) The provider must submit a manufacturer's invoice to document the name, strength, and dosage on the claim form when billing ((MAA)) the department for the following drugs:

     (i) Classified drugs where the billed charge to ((MAA)) the department is over one thousand, one hundred dollars; and

     (ii) Unclassified drugs where the billed charge to ((MAA)) the department is over one hundred dollars. This does not apply to unclassified antineoplastic drugs.

     (10) ((MAA)) The department reimburses allergen immunotherapy only as follows:

     (a) Antigen/antigen preparation codes are reimbursed per dose.

     (b) When a single client is expected to use all the doses in a multiple dose vial, the provider may bill the total number of doses in the vial at the time the first dose from the vial is used. When remaining doses of a multiple dose vial are injected at subsequent times, ((MAA)) the department reimburses the injection service (administration fee) only.

     (c) When a multiple dose vial is used for more than one client, the provider must bill the total number of doses provided to each client out of the multiple dose vial.

     (d) ((MAA)) The department covers the antigen, the antigen preparation, and an administration fee.

     (e) ((MAA)) The department reimburses a provider separately for an E&M service if there is a diagnosis for conditions unrelated to allergen immunotherapy.

     (f) ((MAA)) The department reimburses for RAST testing when the physician has written documentation in the client's record indicating that previous skin testing failed and was negative.

     (11) ((MAA)) The department reimburses for chemotherapy drugs:

     (a) Administered in the physician's office only when:

     (i) The physician personally supervises the E&M services furnished by office medical staff; and

     (ii) The medical record reflects the physician's active participation in or management of course of treatment.

     (b) At established maximum allowable fees that are based on the medicare pricing method for calculating the estimated acquisition cost (EAC), or maximum allowable cost (MAC) when generics are available;

     (c) For unclassified antineoplastic drugs, the provider must submit the following information on the claim form:

     (i) The name of the drug used;

     (ii) The dosage and strength used; and

     (iii) The national drug code (NCD).

     (12) Notwithstanding the provisions of this section, ((MAA)) the department reserves the option of determining drug pricing for any particular drug based on the best evidence available to ((MAA)) the department, or other good and sufficient reasons (e.g., fairness/equity, budget), regarding the actual cost, after discounts and promotions, paid by typical providers nationally or in Washington state.

     (13) ((MAA)) The department may request an invoice as necessary.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0950, filed 12/6/00, effective 1/6/01.]

     Reviser's note: The typographical errors in the above section occurred in the copy filed by the agency and appear in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending WSR 01-01-012, filed 12/6/00, effective 1/6/01)

WAC 388-531-1050   Osteopathic manipulative treatment.   (1) ((MAA)) The department reimburses osteopathic manipulative therapy (OMT) only when OMT is provided by an osteopathic physician licensed under chapter 18.71 RCW.

     (2) ((MAA)) The department reimburses OMT only when the provider bills using the appropriate CPT codes that involve the number of body regions involved.

     (3) ((MAA)) The department allows an osteopathic physician to bill ((MAA)) the department for an evaluation and management (E&M) service in addition to the OMT when one of the following apply:

     (a) The physician diagnoses the condition requiring manipulative therapy and provides it during the same visit;

     (b) The existing related diagnosis or condition fails to respond to manipulative therapy or the condition significantly changes or intensifies, requiring E&M services beyond those included in the manipulation codes; or

     (c) The physician treats the client during the same encounter for an unrelated condition that does not require manipulative therapy.

     (4) ((MAA)) The department limits reimbursement for manipulations to ten per client, per calendar year. Reimbursement for each manipulation includes a brief evaluation as well as the manipulation.

     (5) ((MAA)) The department does not reimburse for physical therapy services performed by osteopathic physicians.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-1050, filed 12/6/00, effective 1/6/01.]

     (2) Out-of-state border areas as described under WAC 388-501-0175 are not subject to out-of-state limitations. ((MAA)) The department considers physicians in border areas as providers in the state of Washington.

     (3) In order to be eligible for reimbursement, out-of-state physicians must meet all criteria for, and must comply with all procedures required of in-state physicians, in addition to other requirements of this chapter.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-1100, filed 12/6/00, effective 1/6/01.]

     (a) A physician provides the service; and

     (b) The client is served by a home health agency, a nursing facility, or a hospice.

     (2) ((MAA)) The department reimburses for physician care plan oversight services when both of the following apply:

     (a) The facility/agency has established a plan of care; and

     (b) The physician spends thirty or more minutes per calendar month providing oversight for the client's care.

     (3) ((MAA)) The department reimburses only one physician per client, per month, for physician care plan oversight services.

     (4) ((MAA)) The department reimburses for physician care plan oversight services during the global surgical reimbursement period only when the care plan oversight is unrelated to the surgery.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-1150, filed 12/6/00, effective 1/6/01.]

     (a) Supplies that are a routine part of office or other outpatient procedures and that cannot be billed separately; and

     (b) Supplies that can be billed separately and that ((MAA)) the department considers nonroutine to office or outpatient procedures.

     (2) ((MAA)) The department reimburses at acquisition cost certain supplies under fifty dollars that do not have a maximum allowable fee listed in the fee schedule. The provider must retain invoices for these items and make them available to ((MAA)) the department upon request.

     (3) Providers must submit invoices for items costing fifty dollars or more.

     (4) ((MAA)) The department reimburses for sterile tray for certain surgical services only. Refer to the fee schedule for a list of covered items.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-1200, filed 12/6/00, effective 1/6/01.]

     (a) The services are provided in conjunction with newborn care history and examination, or result in an admission to a neonatal intensive care unit on the same day; or

     (b) A physician requests another physician to stand by, resulting in the prolonged attendance by the second physician without face-to-face client contact.

     (2) ((MAA)) The department does not reimburse physician standby services when any of the following occur:

     (a) The standby ends in a surgery or procedure included in a global surgical reimbursement;

     (b) The standby period is less than thirty minutes; or

     (c) Time is spent proctoring another physician.

     (3) One unit of physician standby service equals thirty minutes. ((MAA)) The department reimburses subsequent periods of physician standby service only when full thirty minutes of standby is provided for each unit billed. ((MAA)) The department rounds down fractions of a thirty-minute time unit.

     (4) The provider must clearly document the need for physician standby services in the client's medical record.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-1250, filed 12/6/00, effective 1/6/01.]

     (a) A medical doctor;

     (b) A doctor of osteopathy; or

     (c) A podiatric physician.

     (2) ((MAA)) The department reimburses for the following:

     (a) Nonroutine foot care when a medical condition that affects the feet (such as diabetes or arteriosclerosis obliterans) requires that any of the providers in subsection (1) of this section perform such care;

     (b) One treatment in a sixty-day period for debridement of nails. ((MAA)) The department covers additional treatments in this period if documented in the client's medical record as being medically necessary;

     (c) Impression casting. ((MAA)) The department includes ninety-day follow-up care in the reimbursement;

     (d) A surgical procedure performed on the ankle or foot, requiring a local nerve block, and performed by a qualified provider. ((MAA)) The department does not reimburse separately for the anesthesia, but includes it in the reimbursement for the procedure; and

     (e) Custom fitted and/or custom molded orthotic devices:

     (i) ((MAA's)) The department's fee for the orthotic device includes reimbursement for a biomechanical evaluation (an evaluation of the foot that includes various measurements and manipulations necessary for the fitting of an orthotic device); and

     (ii) ((MAA)) The department includes an E&M fee reimbursement in addition to an orthotic fee reimbursement if the E&M services are justified and well documented in the client's medical record.

     (3) ((MAA)) The department does not reimburse podiatrists for any of the following radiology services:

     (a) X rays for soft tissue diagnosis;

     (b) Bilateral X rays for a unilateral condition;

     (c) X rays in excess of two views;

     (d) X rays that are ordered before the client is examined; or

     (e) X rays for any part of the body other than the foot or ankle.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-1300, filed 12/6/00, effective 1/6/01.]

     (a) Consist of face-to-face contact between the physician and the client; and

     (b) Be provided with other services.

     (2) ((MAA)) The department allows reimbursement for a prolonged service procedure in addition to an E&M procedure or consultation, up to three hours per client, per diagnosis, per day, subject to other limitations in the CPT codes that may be used. The applicable CPT codes are indicated in the fee schedule.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-1350, filed 12/6/00, effective 1/6/01.]

     (2) ((MAA)) The department does not make separate payments for contrast material. The exception is low osmolar contrast media (LOCM) used in intrathecal, intravenous, and intra-arterial injections. Clients receiving these injections must have one or more of the following conditions:

     (a) A history of previous adverse reaction to contrast material. An adverse reaction does not include a sensation of heat, flushing, or a single episode of nausea or vomiting;

     (b) A history of asthma or allergy;

     (c) Significant cardiac dysfunction including recent or imminent cardiac decompensation, severe arrhythmias, unstable angina pectoris, recent myocardial infarction, and pulmonary hypertension;

     (d) Generalized severe debilitation;

     (e) Sickle cell disease;

     (f) Pre-existing renal insufficiency; and/or

     (g) Other clinical situations where use of any media except LOCM would constitute a danger to the health of the client.

     (3) ((MAA)) The department reimburse separately for radiopharmaceutical diagnostic imaging agents for nuclear medicine procedures. Providers must submit invoices for these procedures when requested by ((MAA)) the department, and reimbursement is at acquisition cost.

     (4) ((MAA)) The department reimburses general anesthesia for radiology procedures. See WAC 388-531-0300.

     (5) ((MAA)) The department reimburses radiology procedures in combination with other procedures according to the rules for multiple surgeries. See WAC 388-531-1700. The procedures must meet all of the following conditions:

     (a) Performed on the same day;

     (b) Performed on the same client; and

     (c) Performed by the same physician or more than one member of the same group practice.

     (6) ((MAA)) The department reimburses consultation on X-ray examinations. The consulting physician must bill the specific radiological X-ray code with the appropriate professional component modifier.

     (7) ((MAA)) The department reimburses for portable X-ray services furnished in the client's home or in nursing facilities, limited to the following:

     (a) Chest or abdominal films that do not involve the use of contract media;

     (b) Diagnostic mammograms; and

     (c) Skeletal films involving extremities, pelvis, vertebral column or skull.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-1450, filed 12/6/00, effective 1/6/01.]

     Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending WSR 01-01-012, filed 12/6/00, effective 1/6/01)

WAC 388-531-1500   Sleep studies.   (1) ((MAA)) The department covers sleep studies only when all of the following apply:

     (a) The study is done to establish a diagnosis of narcolepsy or of sleep apnea;

     (b) The study is done only at ((an MAA-approved)) a department-approved sleep study center that meets the standards and conditions in subsections (2), (3), and (4) of this section; and

     (c) An ENT consultation has been done for a client under ten years of age.

     (2) In order to become ((an MAA-approved)) a department-approved sleep study center, a sleep lab must send ((MAA)) to the department verification of both of the following:

     (a) Sleep lab accreditation by the American Academy of Sleep Medicine; and

     (b) Physician's Board Certification by the American Board of Sleep Medicine.

     (3) Registered polysomnograph technicians (PSGT) must meet the accreditation standards of the American Academy of Sleep Medicine.

     (4) When a sleep lab changes directors, ((MAA)) the department requires the provider to submit accreditation for the new director. If an accredited director moves to a facility that ((MAA)) the department has not approved, the provider must submit certification for the facility.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-1500, filed 12/6/00, effective 1/6/01.]

STERILIZATION

     (2) ((MAA)) The department covers sterilization when all of the following apply:

     (a) The client is at least eighteen years of age at the time consent is signed;

     (b) The client is a mentally competent individual;

     (c) The client has voluntarily given informed consent in accordance with all the requirements defined in this subsection; and

     (d) At least thirty days, but not more than one hundred eighty days, have passed between the date the client gave informed consent and the date of the sterilization.

     (3) ((MAA)) The department does not require the thirty-day waiting period, but does require at least a seventy-two hour waiting period, for sterilization in the following circumstances:

     (a) At the time of premature delivery, the client gave consent at least thirty days before the expected date of delivery. The expected date of delivery must be documented on the consent form;

     (b) For emergency abdominal surgery, the nature of the emergency must be described on the consent form.

     (4) ((MAA)) The department waives the thirty-day consent waiting period for sterilization when the client requests that sterilization be performed at the time of delivery, and completes a sterilization consent form. One of the following circumstances must apply:

     (a) The client became eligible for medical assistance during the last month of pregnancy;

     (b) The client did not obtain medical care until the last month of pregnancy; or

     (c) The client was a substance abuser during pregnancy, but is not using alcohol or illegal drugs at the time of delivery.

     (5) ((MAA)) The department does not accept informed consent obtained when the client is in any of the following conditions:

     (a) In labor or childbirth;

     (b) Seeking to obtain or obtaining an abortion; or

     (c) Under the influence of alcohol or other substances that affect the client's state of awareness.

     (6) ((MAA)) The department has certain consent requirements that the provider must meet before ((MAA)) the department reimburses sterilization of a mentally incompetent or institutionalized client. ((MAA)) The department requires both of the following:

     (a) A court order; and

     (b) A sterilization consent form signed by the legal guardian, sent to ((MAA)) the department at least thirty days prior to the procedure.

     (7) ((MAA)) The department reimburses epidural anesthesia in excess of the six-hour limit for sterilization procedures that are performed in conjunction with or immediately following a delivery. ((MAA)) The department determines total billable units by:

     (a) Adding the time for the sterilization procedure to the time for the delivery; and

     (b) Determining the total billable units by adding together the delivery BAUs, the delivery time, and the sterilization time.

     (c) The provider cannot bill separately for the BAUs for the sterilization procedure.

     (8) The physician identified in the "consent to sterilization" section of the ((DSHS-approved)) department-approved sterilization consent form must be the same physician who completes the "physician's statement" section and performs the sterilization procedure. If a different physician performs the sterilization procedure, the client must sign and date a new consent form at the time of the procedure that indicates the name of the physician performing the operation under the "consent for sterilization" section. This modified consent must be attached to the original consent form when the provider bills ((MAA)) the department.

     (9) ((MAA)) The department reimburses all attending providers for the sterilization procedure only when the provider submits an appropriate, completed DSHS-approved consent form with the claim for reimbursement. ((MAA)) The department reimburses after the procedure is completed.

HYSTERECTOMY

     (10) Hysterectomies performed for medical reasons may require expedited prior authorization as explained in WAC 388-531-0200(2).

     (11) ((MAA)) The department reimburses hysterectomy without prior authorization in either of the following circumstances:

     (a) The client has been diagnosed with cancer(s) of the female reproductive organs; and/or

     (b) The client is forty-six years of age or older.

     (12) ((MAA)) The department reimburses all attending providers for the hysterectomy procedure only when the provider submits an appropriate, completed DSHS-approved consent form with the claim for reimbursement. If a prior authorization number is necessary for the procedure, it must be on the claim. ((MAA)) The department reimburses after the procedure is completed.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-1550, filed 12/6/00, effective 1/6/01.]

     (2) ((MAA)) The department covers treatment in programs certified under chapter 388-805 WAC or its successor.

     (3) ((MAA)) The department covers detoxification and medical stabilization services to chemically using pregnant (CUP) women for up to twenty-seven days in an inpatient hospital setting.

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. 03-19-081, § 388-531-1650, filed 9/12/03, effective 10/13/03. Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-1650, filed 12/6/00, effective 1/6/01.]

     (a) The operation itself;

     (b) Postoperative dressing changes, including:

     (i) Local incision care and removal of operative packs;

     (ii) Removal of cutaneous sutures, staples, lines, wire, tubes, drains, and splints;

     (iii) Insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; or

     (iv) Change and removal of tracheostomy tubes.

     (c) All additional medical or surgical services required because of complications that do not require additional operating room procedures.

     (2) ((MAA's)) The department's global surgical reimbursement for major surgeries, includes all of the following:

     (a) Preoperative visits, in or out of the hospital, beginning on the day before surgery; and

     (b) Services by the primary surgeon, in or out of the hospital, during a standard ninety-day postoperative period.

     (3) ((MAA's)) The department's global surgical reimbursement for minor surgeries includes all of the following:

     (a) Preoperative visits beginning on the day of surgery; and

     (b) Follow-up care for zero or ten days, depending on the procedure.

     (4) When a second physician provides follow-up services for minor procedures performed in hospital emergency departments, ((MAA)) the department does not include these services in the global surgical reimbursement. The physician may bill these services separately.

     (5) ((MAA's)) The department's global surgical reimbursement for multiple surgical procedures is as follows:

     (a) Payment for multiple surgeries performed on the same client on the same day equals one hundred percent of ((MAA's)) the department's allowed fee for the highest value procedure. Then,

     (b) For additional surgical procedures, payment equals fifty percent of ((MAA's)) the department's allowed fee for each procedure.

     (6) ((MAA)) The department allows separate reimbursement for any of the following:

     (a) The initial evaluation or consultation;

     (b) Preoperative visits more than one day before the surgery;

     (c) Postoperative visits for problems unrelated to the surgery; and

     (d) Postoperative visits for services that are not included in the normal course of treatment for the surgery.

     (7) ((MAA's)) The department's reimbursement for endoscopy is as follows:

     (a) The global surgical reimbursement fee includes follow-up care for zero or ten days, depending on the procedure.

     (b) Multiple surgery rules apply when a provider bills multiple endoscopies from different endoscopy groups. See subsection (4) of this section.

     (c) When a physician performs more than one endoscopy procedure from the same group on the same day, ((MAA)) the department pays the full amount of the procedure with the highest maximum allowable fee.

     (d) ((MAA)) The department pays the procedure with the second highest maximum allowable fee at the maximum allowable fee minus the base diagnostic endoscopy procedure's maximum allowed amount.

     (e) ((MAA)) The department does not pay when payment for other codes within an endoscopy group is less than the base code.

     (8) ((MAA)) The department restricts reimbursement for surgery assists to selected procedures as follows:

     (a) ((MAA)) The department applies multiple surgery reimbursement rules for surgery assists apply. See subsection (4) of this section.

     (b) Surgery assists are reimbursed at twenty percent of the maximum allowable fee for the surgical procedure.

     (c) A surgical assist fee for a registered nurse first assistant (RNFA) is reimbursed if the nurse has been assigned a provider number.

     (d) A provider must use a modifier on the claim with the procedure code to identify surgery assist.

     (9) ((MAA)) The department bases payment splits between preoperative, intraoperative, and postoperative services on medicare determinations for given surgical procedures or range of procedures. ((MAA)) The department pays any procedure that does not have an established medicare payment split according to a split of ten percent - eighty percent - ten percent respectively.

     (10) For preoperative and postoperative critical care services provided during a global period refer to WAC 388-531-0450.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-1700, filed 12/6/00, effective 1/6/01.]

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-1750, filed 12/6/00, effective 1/6/01.]

GENERAL PAYMENT METHODOLOGY

     (l) ((MAA)) The department bases the payment methodology for most physician-related services on medicare's RBRVS. ((MAA)) The department obtains information used to update ((MAA's)) the department's RBRVS from the MPFSPS.

     (2) ((MAA)) The department updates and revises the following RBRVS areas each January prior to ((MAA's)) the department's annual update.

     (3) ((MAA)) The department determines a budget-neutral conversion factor (CF) for each RBRVS update, by:

     (a) Determining the units of service and expenditures for a base period. Then,

     (b) Applying the latest medicare RVU obtained from the MPFSDB, as published in the MPFSPS, and GCPI changes to obtain projected units of service for the new period. Then,

     (c) Multiplying the projected units of service by conversion factors to obtain estimated expenditures. Then,

     (d) Comparing expenditures obtained in (c) of this subsection with base period expenditure levels.

     (e) Adjusting the dollar amount for the conversion factor until the product of the conversion factor and the projected units of service at the new RVUs equals the base period amount.

     (4) ((MAA)) The department calculates maximum allowable fees (MAFs) in the following ways:

     (a) For procedure codes that have applicable medicare RVUs, the three components (practice, malpractice, and work) of the RVU are:

     (i) Each multiplied by the statewide GPCI. Then,

     (ii) The sum of these products is multiplied by the applicable conversion factor. The resulting RVUs are known as RBRVS RVUs.

     (b) For procedure codes that have no applicable medicare RVUs, RSC RVUs are established in the following way:

     (i) When there are three RSC RVU components (practice, malpractice, and work):

     (A) Each component is multiplied by the statewide GPCI. Then,

     (B) The sum of these products is multiplied by the applicable conversion factor.

     (ii) When the RSC RVUs have just one component, the RVU is not GPCI adjusted and the RVU is multiplied by the applicable conversion factor.

     (c) For procedure codes with no RBRVS or RSC RVUs, ((MAA)) the department establishes maximum allowable fees, also known as "flat" fees.

     (i) ((MAA)) The department does not use the conversion factor for these codes.

     (ii) ((MAA)) The department updates flat fee reimbursement only when the legislature authorizes a vendor rate increase, except for the following categories which are revised annually during the update:

     (A) Immunization codes are reimbursed at EAC. (See WAC 388-530-1050 for explanation of EAC.) When the provider receives immunization materials from the department of health, ((MAA)) the department pays the provider a flat fee only for administering the immunization.

     (B) A cast material maximum allowable fee is set using an average of wholesale or distributor prices for cast materials.

     (iii) Other supplies are reimbursed at physicians' acquisition cost, based on manufacturers' price sheets. Reimbursement applies only to supplies that are not considered part of the routine cost of providing care (e.g., intrauterine devices (IUDs)).

     (d) For procedure codes with no RVU or maximum allowable fee, ((MAA)) the department reimburses "by report." By report codes are reimbursed at a percentage of the amount billed for the service.

     (e) For supplies that are dispensed in a physician's office and reimbursed separately, the provider's acquisition cost when flat fees are not established.

     (f) ((MAA)) The department reimburses at acquisition cost those HCPCS J and Q codes that do not have flat fees established.

     (5) The technical advisory group reviews RBRVS changes.

     (6) ((MAA)) The department also makes fee schedule changes when the legislature grants a vendor rate increase and the effective date of that increase is not the same as ((MAA's)) the department's annual update.

     (7) If the legislatively authorized vendor rate increase, or other increase, becomes effective at the same time as the annual update, ((MAA)) the department applies the increase after calculating budget-neutral fees. ((MAA)) The department pays providers a higher reimbursement rate for primary health care E&M services that are provided to children age twenty and under.

     (8) ((MAA)) The department does not allow separate reimbursement for bundled services. However, ((MAA)) the department allows separate reimbursement for items considered prosthetics when those items are used for a permanent condition and are furnished in a provider's office.

     (9) Variations of payment methodology which are specific to particular services and which differ from the general payment methodology described in this section are included in the sections dealing with those particular services.

CPT/HCFA MODIFIERS

     (10) A modifier is a code a provider uses on a claim in addition to a billing code for a standard procedure. Modifiers eliminate the need to list separate procedures that describe the circumstance that modified the standard procedure. A modifier may also be used for information purposes.

     (11) Certain services and procedures require modifiers in order for ((MAA)) the department to reimburse the provider. This information is included in the sections dealing with those particular services and procedures, as well as the fee schedule.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-1850, filed 12/6/00, effective 1/6/01.]

     (2) In order to be reimbursed, physicians must bill ((MAA)) the department according to the conditions of payment under WAC 388-501-0150 and other issuances.

     (3) ((MAA)) The department does not separately reimburse certain administrative costs or services. ((MAA)) The department considers these costs to be included in the reimbursement. These costs and services include the following:

     (a) Delinquent payment fees;

     (b) Educational supplies;

     (c) Mileage;

     (d) Missed or canceled appointments;

     (e) Reports, client charts, insurance forms, copying expenses;

     (f) Service charges;

     (g) Take home drugs; and

     (h) Telephoning (e.g., for prescription refills).

     (4) ((MAA)) The department does not routinely pay for procedure codes which have a "#" indicator in the fee schedule. ((MAA)) The department reviews these codes for conformance to medicaid program policy only as an exception to policy or as a limitation extension. See WAC 388-501-0160 and 388-501-0165.

[Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-1900, filed 12/6/00, effective 1/6/01.]

     (a) Be a department-approved family planning provider as described in WAC 388-532-050;

     (b) Sign the supplemental TAKE CHARGE agreement to participate in the TAKE CHARGE demonstration and research program according to the department's TAKE CHARGE program guidelines;

     (c) Participate in the department's specialized training for the TAKE CHARGE demonstration and research program prior to providing TAKE CHARGE services. Providers must document that each individual responsible for providing TAKE CHARGE services is trained on all aspects of the TAKE CHARGE program;

     (d) Comply with the required general department and TAKE CHARGE provider policies, procedures, and administrative practices as detailed in the department's billing instructions and provide referral information to clients regarding available and affordable nonfamily planning primary care services;

     (e) If requested by the department, participate in the research and evaluation component of the TAKE CHARGE demonstration and research program.

     (f) Forward the client's ((medical identification)) services card and TAKE CHARGE brochure to the client within seven working days of receipt unless otherwise requested in writing by the client;

     (g) Inform the client of his or her right to seek services from any TAKE CHARGE provider within the state; and

     (h) Refer the client to available and affordable nonfamily planning primary care services, as needed.

     (2) Department providers (e.g., pharmacies, laboratories, surgeons performing sterilization procedures) who are not TAKE CHARGE providers may furnish family planning ancillary TAKE CHARGE services, as defined in this chapter, to eligible (([TAKE CHARGE])) TAKE CHARGE clients. The department reimburses for these services under the rules and fee schedules applicable to the specific services provided under the department's other programs.

[Statutory Authority: RCW 74.08.090 and 74.09.800. 08-11-031, § 388-532-730, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. 05-24-032, § 388-532-730, filed 11/30/05, effective 12/31/05. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800, and SSB 5968, 1999 c 392 § 2(12). 02-21-021, § 388-532-730, filed 10/8/02, effective 11/8/02.]

     (1) TAKE CHARGE application form(s);

     (2) Signed supplemental TAKE CHARGE agreement to participate in the TAKE CHARGE program;

     (3) Documentation of the department's specialized TAKE CHARGE training and/or in-house in-service TAKE CHARGE training for each individual responsible for providing TAKE CHARGE.

     (4) Chart notes that reflect the primary focus and diagnosis of the visit was family planning;

     (5) Contraceptive methods discussed with the client;

     (6) Notes on any discussions of emergency contraception and needed prescription(s);

     (7) The client's plan for the contraceptive method to be used, or the reason for no contraceptive method and plan;

     (8) Documentation of the education, counseling and risk reduction (ECRR) service, if provided, with sufficient detail that allows for follow-up;

     (9) Documentation of referrals to or from other providers;

     (10) A form signed by the client authorizing release of information for referral purposes, as necessary;

     (11) The client's written and signed consent requesting that his or her ((medical identification)) services card be sent to the TAKE CHARGE provider's office to protect confidentiality;

     (12) A copy of the client's picture identification;

     (13) A copy of the documentation used to establish United States citizenship or legal permanent residency; and

     (14) If applicable, a copy of the completed ((DSHS)) department sterilization consent form (DSHS 13-364 - available for download at http://www.dshs.wa.gov/msa/forms/eforms.html) (see WAC 388-531-1550).

[Statutory Authority: RCW 74.08.090 and 74.09.800. 08-11-031, § 388-532-760, filed 5/13/08, effective 6/13/08. Statutory Authority: RCW 74.08.090, 74.09.520, and 74.09.800. 05-24-032, § 388-532-760, filed 11/30/05, effective 12/31/05. Statutory Authority: RCW 74.08.090, 74.09.520, 74.09.800, and SSB 5968, 1999 c 392 § 2(12). 02-21-021, § 388-532-760, filed 10/8/02, effective 11/8/02.]

     (1) For the purposes of this section, ((foster care)) out-of-home placement is defined as twenty-four hour per day, temporary, substitute care for a child:

     (a) Placed away from the child's parents or guardians in licensed, paid, out-of-home care; and

     (b) For whom the department or a licensed or certified child placing agency has placement and care responsibility.

     (2) ((MAA)) The department pays an enhanced ((flat)) fee to the providers listed in subsection (3) of this section for EPSDT ((screens)) exams provided to only those children ((receiving foster care)) in out-of-home placement ((services from DSHS)).

     (3) The following providers are eligible to perform EPSDT ((screens)) exams and bill ((MAA)) the enhanced rate for children ((receiving foster care)) in out-of-home placement ((services from DSHS)):

     (a) EPSDT clinics;

     (b) Physicians;

     (c) Advanced registered nurse practitioners (ARNPs);

     (d) Physician assistants (PAs) working under the guidance ((and MAA provider number)) of a physician;

     (e) Nurses specially trained through the department of health (DOH) to perform EPSDT ((screens)) exams; and

     (f) Registered nurses working under the guidance ((and MAA provider number)) of a physician or ARNP.

     (4) In order to be paid an enhanced fee, services furnished by the providers listed in subsection (3) of this section must meet the federal requirements for EPSDT ((screens)) exams at 42 CFR Part 441 Subpart B, which were in effect as of December 1, 2001.

     (5) The provider must retain documentation of the EPSDT ((screens)) exams in the client's medical file. The provider must use the ((DSHS)) department's Well Child Exam forms or provide equivalent information. ((DSHS)) The Well Child Exam forms include the required elements for an EPSDT exam. The Well Child Exam forms (DSHS 13-683A through 13-686B) are available for downloading at no charge ((by sending a request in writing or by fax to:

     DSHS Warehouse

     P.O. Box 45816

     Olympia, WA. 98504-5816

     fax: 360-664-0597)) at http://www1.dshs.wa.gov/msa/forms/eforms.html.

     (6) ((MAA)) The department conducts evaluations of client files and payments made under this program. ((MAA)) The department may recover the enhanced payment amount when:

     (a) The client was not ((receiving foster care)) in out-of-home placement ((services from DSHS)) as defined in subsection (1) of this section when the EPSDT ((screen)) exam was provided; or

     (b) Documentation was not in the client's medical file (see subsection (5) of this section).

[Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057, 74.08.090, 42 C.F.R., Part 441, Subpart B. 02-07-016, § 388-534-0200, filed 3/8/02, effective 4/8/02.]

     (2) To be eligible for the AIDS health insurance premium payment program, individuals must:

     (a) Be diagnosed with AIDS as defined in WAC 246-100-011;

     (b) Be a resident of the state of Washington;

     (c) Be responsible for all, or part of, the health insurance premium payment (without ((MAA's)) the department's help);

     (d) Not be eligible for one of ((MAA's)) the department's other medical programs;

     (e) Not have personal income that exceeds three hundred seventy percent of the federal poverty level; and

     (f) Not have personal assets, after exemptions, exceeding fifteen thousand dollars. The following personal assets are exempt from the personal assets calculation:

     (i) A home used as the person's primary residence; and

     (ii) A vehicle used as personal transportation.

     (3) ((MAA)) The department may contract with a not-for-profit community agency to administer the Aids health insurance premium payment program. ((MAA)) The department or its contractor determines an individual's initial eligibility and redetermines eligibility on a periodic basis. To be eligible, individuals must:

     (a) Cooperate with ((MAA's)) the department's contractor;

     (b) Cooperate with eligibility determination and redetermination process; and

     (c) Initially meet and continue to meet the eligibility criteria in subsection (2) of this section.

     (4) Individuals, diagnosed with AIDS, who are eligible for one of ((MAA's)) the department's medical programs may ask ((MAA)) the department to pay their health insurance premiums under a separate process. The client's community services office (CSO) is able to assist the client with this process.

     (5) Once an individual is eligible to participate in the AIDS health insurance premium payment program, eligibility would cease only when one of the following occurs. The individual:

     (a) Is deceased;

     (b) Voluntarily quits the program;

     (c) No longer meets the requirements of subsection (2) of this section; or

     (d) Has benefits terminated due to the legislature's termination of the funding for this program.

     (6) ((MAA)) The department sets a reasonable payment limit for health insurance premiums. ((MAA)) The department sets its limit by tracking the charges billed to ((MAA)) the department for ((MAA)) department clients who have AIDS. ((MAA)) The department does not pay health insurance premiums that exceed fifty percent of the average of charges billed to ((MAA)) the department for its clients with AIDS.

[Statutory Authority: RCW 74.08.090, 74.09.757. 00-14-070, § 388-539-0200, filed 7/5/00, effective 8/5/00.]

     Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
AMENDATORY SECTION(Amending WSR 00-23-070, filed 11/16/00, effective 12/17/00)

WAC 388-539-0300   Case management for persons living with HIV/AIDS.   ((MAA)) The department provides HIV/AIDS case management to assist persons infected with HIV to: Live as independently as possible; maintain and improve health; reduce behaviors that put the client and others at risk; and gain access to needed medical, social, and educational services.

     (1) To be eligible for ((MAA)) department reimbursed HIV/AIDS case management services, the person must:

     (a) Have a current medical diagnosis of HIV or AIDS;

     (b) Be eligible for Title XIX (medicaid) coverage under either the categorically needy program (CNP) or the medically needy program (MNP); and

     (c) Require:

     (i) Assistance to obtain and effectively use necessary medical, social, and educational services; or

     (ii) Ninety days of continued monitoring as provided in WAC 388-539-0350(2).

     (2) ((MAA)) The department has an interagency agreement with the Washington state department of health (DOH) to administer the HIV/AIDS case management program for ((MAA's)) the department's Title XIX (medicaid) clients.

     (3) HIV/AIDS case management agencies who serve ((MAA's)) the department's clients must be approved to perform these services by HIV client services, DOH.

     (4) HIV/AIDS case management providers must:

     (a) Notify HIV positive persons of their statewide choice of available HIV/AIDS case management providers and document that notification in the client's record. This notification requirement does not obligate HIV/AIDS case management providers to accept all clients who request their services.

     (b) Have a current client-signed authorization to release/obtain information form. The provider must have a valid authorization on file for the months that case management services are billed to ((MAA)) the department (see RCW 70.02.030). The fee referenced in RCW 70.02.030 is included in ((MAA's)) the department's reimbursement to providers. ((MAA's)) The department's clients may not be charged for services or documents related to covered services.

     (c) Maintain sufficient contact to ensure the effectiveness of ongoing services per subsection (5) of this section. ((MAA)) The department requires a minimum of one contact per month between the HIV/AIDS case manager and the client. However, contact frequency must be sufficient to ensure implementation and ongoing maintenance of the individual service plan (ISP).

     (5) HIV/AIDS case management providers must document services as follows:

     (a) Providers must initiate a comprehensive assessment within two working days of the client's referral to HIV/AIDS case management services. Providers must complete the assessment before billing for ongoing case management services. If the assessment does not meet these requirements, the provider must document the reason(s) for failure to do so. The assessment must include the following elements as reported by the client:

     (i) Demographic information (e.g., age, gender, education, family composition, housing.);

     (ii) Physical status, the identity of the client's primary care provider, and current information on the client's medications/treatments;

     (iii) HIV diagnosis (both the documented diagnosis at the time of assessment and historical diagnosis information);

     (iv) Psychological/social/cognitive functioning and mental health history;

     (v) Ability to perform daily activities;

     (vi) Financial and employment status;

     (vii) Medical benefits and insurance coverage;

     (viii) Informal support systems (e.g., family, friends and spiritual support);

     (ix) Legal status, durable power of attorney, and any self-reported criminal history; and

     (x) Self-reported behaviors which could lead to HIV transmission or re-infection (e.g., drug/alcohol use).

     (b) Providers must develop, monitor, and revise the client's individual service plan (ISP). The ISP identifies and documents the client's unmet needs and the resources needed to assist in meeting the client's needs. The case manager and the client must develop the ISP within two days of the comprehensive assessment or the provider must document the reason this is not possible. An ISP must be:

     (i) Signed by the client, documenting that the client is voluntarily requesting and receiving ((MAA)) the department reimbursed HIV/AIDS case management services; and

     (ii) Reviewed monthly by the case manager through in-person or telephone contact with the client. Both the review and any changes must be noted by the case manager:

     (A) In the case record narrative; or

     (B) By entering notations in, initialing and dating the ISP.

     (c) Maintained ongoing narrative records - These records must document case management services provided in each month for which the provider bills ((MAA)) the department. Records must:

     (i) Be entered in chronological order and signed by the case manager;

     (ii) Document the reason for the case manager's interaction with the client; and

     (iii) Describe the plans in place or to be developed to meet unmet client needs.

[Statutory Authority: RCW 74.08.090, 74.09.755, 74.09.800, 42 U.S.C. Section 1915(g). 00-23-070, § 388-539-0300, filed 11/16/00, effective 12/17/00.]

     (a) Comprehensive assessment - The assessment must cover the areas outlined in WAC 388-539-0300 (1) and (5).

     (i) ((MAA)) The department reimburses only one comprehensive assessment unless the client's situation changes as follows:

     (A) There is a fifty percent change in need from the initial assessment; or

     (B) The client transfers to a new case management provider.

     (ii) ((MAA)) The department reimburses for a comprehensive assessment in addition to a monthly charge for case management (either full-month or partial-month) if the assessment is completed during a month the client is medicaid eligible and the ongoing case management has been provided.

     (b) HIV/AIDS case management, full-month - Providers may request the full-month reimbursement for any month in which the criteria in WAC 388-539-0300 have been met and the case manager has an individual service plan (ISP) in place for twenty or more days in that month. ((MAA)) The department reimburses only one full-month case management fee per client in any one month.

     (c) HIV/AIDS case management, partial-month - Providers may request the partial-month reimbursement for any month in which the criteria in WAC 388-539-0300 have been met and the case manager has an ISP in place for fewer than twenty days in that month. Using the partial-month reimbursement, ((MAA)) the department may reimburse two different case management providers for services to a client who changes from one provider to a new provider during that month.

     (2) ((MAA)) The department limits reimbursement to HIV/AIDS case managers when a client becomes stabilized and no longer needs an ISP with active service elements. ((MAA)) The department limits reimbursement for monitoring to ninety days past the time the last active service element of the ISP is completed. Case Management providers who are monitoring a stabilized client must meet all of the following criteria in order to bill ((MAA)) the department for up to ninety days of monitoring:

     (a) Document the client's history of recurring need;

     (b) Assess the client for possible future instability; and

     (c) Provide monthly monitoring contacts.

     (3) ((MAA)) The department reinstates reimbursement for ongoing case management if a client shifts from monitoring status to active case management status due to documented need(s). Providers must meet the requirements in WAC 388-539-0300 when a client is reinstated to active case management.

[Statutory Authority: RCW 74.08.090, 74.09.755, 74.09.800, 42 U.S.C. Section 1915(g). 00-23-070, § 388-539-0350, filed 11/16/00, effective 12/17/00.]

     (a) Is no longer certified for hospice care;

     (b) Is no longer appropriate for hospice care; or

     (c) The hospice agency's medical director determines the client is seeking treatment for the terminal illness outside the plan of care (POC).

     (2) At the time of a client's discharge, a hospice agency must:

     (a) Within five working days, complete a medicaid hospice 5-day notification form (DSHS 13-746) and forward to the department's hospice program manager (see WAC 388-551-1400 for additional requirements), and a copy to the appropriate home and community services office (HCS) or community services office (CSO);

     (b) Keep the discharge statement in the client's hospice record;

     (c) Provide the client with a copy of the discharge statement; and

     (d) Inform the client that the discharge statement must be:

     (i) Presented with the client's current ((medical identification (medical ID))) services card when obtaining medicaid covered healthcare services or supplies, or both; and

     (ii) Used until the department ((issues the client a new medical ID card that identifies that the client is no longer a hospice client)) removes the hospice restriction from the client's information available online at https://www.waproviderone.org.

[Statutory Authority: RCW 74.08.090, 74.09.520. 05-18-033, § 388-551-1350, filed 8/30/05, effective 10/1/05. Statutory Authority: RCW 74.09.520, 74.08.090, 42 C.F.R. 418.22 and 418.24. 99-09-007, § 388-551-1350, filed 4/9/99, effective 5/10/99.]

[Statutory Authority: RCW 74.08.090, 74.09.530. 04-11-007, § 388-553-100, filed 5/5/04, effective 6/5/04.]

     (a) Categorically needy program (CNP);

     (b) Categorically needy program - Children's health insurance program (CNP-CHIP);

     (c) General assistance - Unemployable (GA-U); and

     (d) Limited casualty program - Medically needy program (LCP-MNP).

     (2) Clients enrolled in ((an MAA)) a department-contracted managed care ((plan)) organization (MCO) are eligible for home infusion therapy and parenteral nutrition through that plan.

     (3) Clients eligible for home health program services may receive home infusion related services according to WAC 388-551-2000 through 388-551-3000.

     (4) To receive home infusion therapy, a client must:

     (a) Have a written physician order for all solutions and medications to be administered.

     (b) Be able to manage their infusion in one of the following ways:

     (i) Independently;

     (ii) With a volunteer caregiver who can manage the infusion; or

     (iii) By choosing to self-direct the infusion with a paid caregiver (see WAC 388-71-0580).

     (c) Be clinically stable and have a condition that does not warrant hospitalization.

     (d) Agree to comply with the protocol established by the infusion therapy provider for home infusions. If the client is not able to comply, the client's caregiver may comply.

     (e) Consent, if necessary, to receive solutions and medications administered in the home through intravenous, enteral, epidural, subcutaneous, or intrathecal routes. If the client is not able to consent, the client's legal representative may consent.

     (f) Reside in a residence that has adequate accommodations for administering infusion therapy including:

     (i) Running water;

     (ii) Electricity;

     (iii) Telephone access; and

     (iv) Receptacles for proper storage and disposal of drugs and drug products.

     (5) To receive parenteral nutrition, a client must meet the conditions in subsection (4) of this section and:

     (a) Have one of the following that prevents oral or enteral intake to meet the client's nutritional needs:

     (i) Hyperemesis gravidarum; or

     (ii) An impairment involving the gastrointestinal tract that lasts three months or longer.

     (b) Be unresponsive to medical interventions other than parenteral nutrition; and

     (c) Be unable to maintain weight or strength.

     (6) A client who has a functioning gastrointestinal tract is not eligible for parenteral nutrition program services when the need for parenteral nutrition is only due to:

     (a) A swallowing disorder;

     (b) Gastrointestinal defect that is not permanent unless the client meets the criteria in subsection (7) of this section;

     (c) A psychological disorder (such as depression) that impairs food intake;

     (d) A cognitive disorder (such as dementia) that impairs food intake;

     (e) A physical disorder (such as cardiac or respiratory disease) that impairs food intake;

     (f) A side effect of medication; or

     (g) Renal failure or dialysis, or both.

     (7) A client with a gastrointestinal impairment that is expected to last less than three months is eligible for parenteral nutrition only if:

     (a) The client's physician or appropriate medial provider has documented in the client's medical record the gastrointestinal impairment is expected to last less ((then)) than three months;

     (b) The client meets all the criteria in subsection (4) of this section;

     (c) The client has a written physician order that documents the client is unable to receive oral or tube feedings; and

     (d) It is medically necessary for the gastrointestinal tract to be totally nonfunctional for a period of time.

     (8) A client is eligible to receive intradialytic parenteral nutrition (IDPN) solutions when:

     (a) The parenteral nutrition is not solely supplemental to deficiencies caused by dialysis; and

     (b) The client meets the criteria in subsection (4) and (5) of this section and other applicable WAC.

[Statutory Authority: RCW 74.08.090, 74.09.530. 04-11-007, § 388-553-300, filed 5/5/04, effective 6/5/04.]

     (a) Have a signed core provider agreement with the ((medical assistance administration (MAA))) department; and

     (b) Be one of the following provider types:

     (i) Pharmacy provider;

     (ii) Durable medical equipment (DME) provider; or

     (iii) Infusion therapy provider.

     (2) ((MAA)) The department pays eligible providers for home infusion supplies and equipment and parenteral nutrition solutions only when the providers:

     (a) Are able to provide home infusion therapy within their scope of practice;

     (b) Have evaluated each client in collaboration with the client's physician, pharmacist, or nurse to determine whether home infusion therapy/parenteral nutrition is an appropriate course of action;

     (c) Have determined that the therapies prescribed and the client's needs for care can be safely met;

     (d) Have assessed the client and obtained a written physician order for all solutions and medications administered to the client in the client's residence or in a dialysis center through intravenous, epidural, subcutaneous, or intrathecal routes;

     (e) Meet the requirements in WAC 388-502-0020, including keeping legible, accurate and complete client charts, and providing the following documentation in the client's medical file:

     (i) For a client receiving infusion therapy, the file must contain:

     (A) A copy of the written prescription for the therapy;

     (B) The client's age, height, and weight; and

     (C) The medical necessity for the specific home infusion service.

     (ii) For a client receiving parenteral nutrition, the file must contain:

     (A) All the information listed in (e)(i) of this subsection;

     (B) Oral or enteral feeding trials and outcomes, if applicable;

     (C) Duration of gastrointestinal impairment; and

     (D) The monitoring and reviewing of the client's lab values:

     (I) At the initiation of therapy;

     (II) At least once per month; and

     (III) When the client and/or the client's lab results are unstable.

[Statutory Authority: RCW 74.08.090, 74.09.530. 04-11-007, § 388-553-400, filed 5/5/04, effective 6/5/04.]

     (a) For ((MAA)) clients who are:

     (i) Under twenty-one years of age; and

     (ii) Referred by a screening provider under the healthy kids/early and periodic screening, diagnosis, and treatment (EPSDT) program.

     (b) That are:

     (i) Medically necessary, safe, effective, and not experimental;

     (ii) Provided by a chiropractor licensed in the state where services are provided; and

     (iii) Within the scope of the chiropractor's license.

     (c) Limited to:

     (i) Chiropractic manipulative treatments of the spine; and

     (ii) X rays of the spine.

     (2) Chiropractic services are paid according to fees established by ((MAA)) the department using methodology set forth in WAC 388-531-1850.

[Statutory Authority: RCW 74.08.090, 74.09.035. 00-16-031, § 388-556-0200, filed 7/24/00, effective 8/24/00.]

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