Effective Date of Rule: July 1, 2012.

     Purpose: Revisions to this rule are necessary in order to:

     (1) Implement 42 C.F.R. 455.410 which mandates states to require all ordering, prescribing, or referring providers to be enrolled as participating providers under the billing providers' core provider agreement in order to receive payment.

     (2) Clarify language regarding the core provider agreement effective date, when a provider may ask for an effective date earlier than the agency's approval of the provider application, and how far back the agency's chief medical officer may authorize an effective date under the exceptions. This clarification is necessary to allow medicaid provider entities that are subject to survey and certification by the Centers for Medicare and Medicaid Services or the state survey agency, a reasonable amount of time to submit their medicare certification letters to the agency.

     Citation of Existing Rules Affected by this Order: Amending WAC 182-502-0005.

     Statutory Authority for Adoption: RCW 41.05.021.

     Other Authority: 42 C.F.R. 455 subpart E Provider Screening and Enrollment requirements.

      Adopted under notice filed as WSR 12-07-028 on March 13, 2012.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.

     Date Adopted: May 29, 2012.

Kevin M. Sullivan

Rules Coordinator

OTS-4621.1

AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-502-0005   Core provider agreement (CPA).   (1) ((All healthcare)) The agency only pays claims submitted by or on behalf of a health care professional((s)), ((healthcare entities)) health care entity, supplier((s)) or contractor((s)) of service ((must have)) that has an approved core provider agreement (CPA) with the agency or ((be enrolled as)) is a performing provider on an approved CPA ((to provide healthcare services to an eligible medical assistance client; otherwise any request for payment will be denied)) with the agency.

     (2) ((For services provided out-of-state refer to WAC 388-501-0180, 388-501-0182 and 388-501-0184.

     (3) All performing providers of services to a medical assistance client must be enrolled under the billing provider's CPA.

     (4) The department does not pay for services provided to clients during the CPA application process, regardless of whether the CPA is later approved or denied, except as provided in subsection (5) of this section.

     (5) Enrollment of a provider applicant is effective no earlier than the date of approval of the provider application.

     (a) Any exceptions must be requested in writing to the medicaid director with justification as to why the applicant's effective date should be prior to the CPA approval date. The requested effective date must be noted and must be covered by any applicable license or certification submitted with this application. Only the medicaid director or the medicaid director's written designee may approve exceptions. Exceptions will only be considered for the following:

     (i) Emergency services;

     (ii) Department-approved out-of-state services;

     (iii) Retroactive client eligibility; or

     (iv) Other critical department need as determined by the medicaid director or the medicaid director's written designee.

     (b) For federally-qualified health centers (FQHCs), see WAC 388-548-1200. For rural health clinics (RHCs), see WAC 388-549-1200.)) Performing providers of services to a medical assistance client must be enrolled under the billing providers' CPA.

     (3) Any ordering, prescribing, or referring providers must be enrolled in the agency's claims payment system in order for any services or supplies ordered, prescribed, or referred by them to be paid. The national provider identifier (NPI) of any referring, prescribing, or ordering provider must be included on the claim form.

     (4) For services provided out-of-state, refer to WAC 182-501-0180, 182-501-0182, and 182-501-0184.

     (5) The agency does not pay for services provided to clients during the CPA application process, regardless of whether the agency later approves or denies the CPA application, except as provided in subsection (6) of this section.

     (6) Enrollment of a provider applicant is effective on the date the agency approves the provider application.

     (a) A provider applicant may ask for an effective date earlier than the agency's approval of the provider application by submitting a written request to the agency's chief medical officer. The request must specify the requested effective date and include an explanation justifying the earlier effective date. The chief medical officer will not authorize an effective date that is:

     (i) Earlier than the effective date of any required license or certification; or

     (ii) More than three hundred sixty-five days prior to the agency's approval of the provider application.

     (b) The chief medical officer or designee may approve exceptions as follows:

     (i) Emergency services;

     (ii) Agency-approved out-of-state services;

     (iii) Medicaid provider entities that are subject to survey and certification by CMS or the state survey agency;

     (iv) Retroactive client eligibility; or

     (v) Other critical agency need as determined by the agency's chief medical officer or designee.

     (c) For federally qualified health centers (FQHCs), see WAC 182-548-1200. For rural health clinics (RHCs), see WAC 182-549-1200.

     (d) Exceptions granted under this subsection (6) do not supersede or otherwise change the agency's timely billing requirements under WAC 182-502-0150.

[11-14-075, recodified as § 182-502-0005, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. 11-11-017, § 388-502-0005, filed 5/9/11, effective 6/9/11.]

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