WSR 13-03-068

PERMANENT RULES

HEALTH CARE AUTHORITY


(Medicaid Program)

[ Filed January 14, 2013, 9:15 a.m. , effective February 14, 2013 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: The health care authority is amending current rules and implementing new rules on provider screening and enrollment in response to the Patient Protection and Affordable Care Act. Implementation of these rules is required by federal law and required to maintain federally delegated or authorized programs.

Citation of Existing Rules Affected by this Order: Amending WAC 182-502-0010, 182-502-0012, 182-502-0014, 182-502-0016, and 182-502-0020.

Statutory Authority for Adoption: RCW 41.05.021.

Other Authority: 42 C.F.R. 455.

Adopted under notice filed as WSR 12-24-088 on December 5, 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Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 5, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 5, Repealed 0.

Date Adopted: January 14, 2012.

Kevin M. Sullivan

Rules Coordinator

OTS-5167.1


AMENDATORY SECTION(Amending WSR 12-15-015, filed 7/10/12, effective 9/1/12)

WAC 182-502-0010   When the medicaid agency enrolls.   (1) Nothing in this chapter obligates the medicaid agency to enroll any eligible health care professional, health care entity, supplier or contractor of service who requests enrollment.

(2) To enroll as a provider with the ((medicaid)) agency, a health care professional, health care entity, supplier or contractor of service must, on the date of application:

(a) Be currently licensed, certified, accredited, or registered according to Washington state laws and rules. Persons or entities outside of Washington state, see WAC 182-502-0120;

(b) Be enrolled with medicare, when required in specific program rules;

(c) Have current professional liability coverage, individually or as a member of a group;

(d) Have a current federal drug enforcement agency (DEA) certificate, if applicable to the profession's scope of practice;

(e) Meet the conditions in this chapter and other chapters regulating the specific type of health care practitioner;

(f) Sign, without modification, a core provider agreement (CPA) (HCA 09-015), disclosure of ownership form, and debarment form (((09-048))) (HCA 09-016) or a contract with the agency((. (Note: Section 13 of the CPA, 09-048 (REV. 08/2005), is hereby rescinded. The medicaid agency and each provider signing a core provider agreement will hold each other harmless from a legal action based on the negligent actions or omissions of either party under the terms of the agreement.)));

(g) Agree to accept the payment from the ((medicaid)) agency as payment in full (in accordance with 42 C.F.R. 447.15 acceptance of state payment as payment in full and WAC 182-502-0160 billing a client);

(h) Fully disclose ownership, employees who manage, and other control ((information)) interests (e.g., member of a board of directors or office), as requested by the agency. Indian health services clinics are exempt from this requirement. If payment for services is to be made to a group practice, partnership, or corporation, the group, partnership, or corporation must enroll and ((obtain a CPA number)) provide its national provider identifier (NPI) (if eligible for an NPI) to be used for submitting claims as the billing provider((. All owners must be identified and fully disclosed in the application)); ((and))

(i) Have screened employees and contractors with whom they do business prior to hiring or contracting to assure that employees and contractors are not excluded from receiving federal funds as required by 42 U.S.C. 1320a-7 and 42((.)) U.S.C. 1320c-5;

(j) Pass the agency's screening process, including license verifications, data base checks, site visits, and criminal background checks, including fingerprint-based criminal background checks as required by 42 C.F.R. 455.434 if considered high-risk under 42 C.F.R. 455.450. The agency uses the same screening level risk categories that apply under medicare. For those provider types that are not recognized under medicare, the agency assesses the risk of fraud, waste, and abuse using similar criteria to those used in medicare; and

(k) Agree to pay an application fee, if required by CMS under 42 C.F.R. 455.460.

[Statutory Authority: RCW 41.05.021 and Affordable Care Act (ACA) - 76 Fed. Reg. 5862, 42 C.F.R. Parts 405, 424, 447, 455, 457, and 498. 12-15-015, 182-502-0010, filed 7/10/12, effective 9/1/12. 11-14-075, recodified as 182-502-0010, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. 11-11-017, 388-502-0010, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.09.521. 08-12-030, 388-502-0010, filed 5/29/08, effective 7/1/08. Statutory Authority: RCW 74.08.090, 74.09.080, 74.09.120. 03-14-106, 388-502-0010, filed 6/30/03, effective 7/31/03. Statutory Authority: RCW 74.08.090, 74.09.500, and 74.09.530. 01-07-076, 388-502-0010, filed 3/20/01, effective 4/20/01; 00-15-050, 388-502-0010, filed 7/17/00, effective 8/17/00.]


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

WAC 182-502-0012   When the ((department)) medicaid agency does not enroll.   (1) The ((department)) medicaid agency does not enroll a health care professional, health care entity, supplier or contractor of service for reasons which include, but are not limited to, the following:

(a) The ((department)) agency determines that:

(i) There is a quality of care issue with significant risk factors that may endanger client health and/or safety (see WAC ((388-502-0030)) 182-502-0030 (1)(a)); or

(ii) There are risk factors that affect the credibility, honesty, or veracity of the health care practitioner (see WAC ((388-502-0030)) 182-502-0030 (1)(b)).

(b) The health care professional, health care entity, supplier or contractor of service:

(i) Is excluded from participation in medicare, medicaid or any other federally funded health care program;

(ii) Has a current formal or informal pending disciplinary action, statement of charges, or the equivalent from any state or federal professional disciplinary body at the time of initial application;

(iii) Has been disciplined based on allegation of sexual misconduct or admitted to sexual misconduct;

(iv) Has a suspended, terminated, revoked, or surrendered professional license as defined under chapter 18.130 RCW;

(v) Has a restricted, suspended, terminated, revoked, or surrendered professional license in any state;

(vi) Is noncompliant with the department of health's or other state health care agency's stipulation of informal disposition, agreed order, final order, or similar licensure restriction;

(vii) Is suspended or terminated by any agency within the state of Washington that arranges for the provision of health care;

(viii) Fails a background check, including a fingerprint-based criminal background check, performed by the ((department)) agency. See WAC ((388-502-0014)) 182-502-0014 and ((388-502-0016)) 182-502-0016; ((or))

(ix) Does not have sufficient liability insurance according to WAC ((388-502-0016)) 182-502-0016 for the scope of practice; or

(x) Fails to meet the requirements of a site visit, as required by 42 C.F.R. 455.432.

(2) The ((department)) agency may not pay for any health care service, drug, supply or equipment prescribed or ordered by a health care professional, health care entity, supplier or contractor of service whose application for a core provider agreement (CPA) has been denied or terminated.

(3) The ((department)) agency may not pay for any health care service, drug, supply, or equipment prescribed or ordered by a health care professional, health care entity, supplier or contractor of service who does not have a current CPA with the ((department)) agency when the ((department)) agency determines there is a potential danger to a client's health and/or safety.

(4) Nothing in this chapter precludes the ((department)) agency from entering into other forms of written agreements with a health care professional, health care entity, supplier or contractor of service.

(5) If the ((department)) agency denies an enrollment application, the applicant does not have any dispute rights within the ((department)) agency.

(6) Under 42 C.F.R. 455.470, the agency:

(a) Will impose a temporary moratorium on enrollment when directed by CMS; or

(b) May initiate and impose a temporary moratorium on enrollment when approved by CMS.

[11-14-075, recodified as 182-502-0012, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. 11-11-017, 388-502-0012, filed 5/9/11, effective 6/9/11.]


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

WAC 182-502-0014   Review and consideration of an applicant's history.   (1) The ((department)) medicaid agency may consider enrolling a health care professional, health care entity, supplier or contractor of service for reasons which include, but are not limited to, the following:

(a) The ((department)) agency determines that:

(i) There is not a quality of care issue with significant risk factors that endanger client health ((and/))or safety, or both;

(ii) There are not risk factors that affect the credibility, honesty, or veracity of the applicant; and

(iii) The applicant is not likely to repeat the violation that led to a restriction or sanction.

(b) The health care professional, health care entity, supplier or contractor of service has:

(i) Been excluded from participation in medicare, medicaid, or any other federally funded health care program but is not currently excluded; or

(ii) A history of probation, suspension, termination, revocation, or a surrendered professional license, certification, accreditation, or registration as defined under chapter 18.130 RCW but currently has an active license, certification, accreditation, or registration; or

(iii) A restricted or limited professional license, certification, accreditation, or registration as defined under RCW 18.130.160; or

(iv) A history of denial, limitation, suspension or termination of participation or privileges by any health care institution, plan, facility, clinic, or state agency for quality of care issues or inappropriate billing practices and the quality of care issue or inappropriate billing practices have been corrected to the ((department's)) agency's satisfaction.

(2) The ((department may conduct a background check)) agency conducts a screening process as specified in WAC 182-502-0010 (2)(j) on any applicant applying for a core provider agreement (CPA) or enrolling to provide services to eligible clients.

(3) The ((department's)) agency's response to a review of a request for enrollment is based on the information available to the ((department)) agency at the time of application.

[11-14-075, recodified as 182-502-0014, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. 11-11-017, 388-502-0014, filed 5/9/11, effective 6/9/11.]


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

WAC 182-502-0016   Continuing requirements.   (1) To continue to provide services for eligible clients and be paid for those services, a provider must:

(a) Provide all services without discriminating on the grounds of race, creed, color, age, sex, sexual orientation, religion, national origin, marital status, the presence of any sensory, mental or physical handicap, or the use of a trained dog guide or service animal by a person with a disability;

(b) Provide all services according to federal and state laws and rules, ((department)) medicaid agency billing instructions, numbered memoranda issued by the ((department)) agency, and other written directives from the ((department)) agency;

(c) Inform the ((department)) agency of any changes to the provider's application or contract, including but not limited to, changes in:

(i) Ownership (see WAC ((388-502-0018)) 182-502-0018);

(ii) Address or telephone number;

(iii) Professional practicing under the billing provider number; or

(iv) Business name.

(d) Retain a current professional state license, registration, certification and((/or)) applicable business license for the service being provided, and update the ((department)) agency of all changes;

(e) Inform the ((department)) agency in writing within seven calendar days of changes applicable to the provider's clinical privileges;

(f) Inform the ((department)) agency in writing within seven business days of receiving any informal or formal disciplinary order, decision, disciplinary action or other action(s), including, but not limited to, restrictions, limitations, conditions and suspensions resulting from the practitioner's acts, omissions, or conduct against the provider's license, registration, or certification in any state;

(g) Screen employees and contractors with whom they do business prior to hiring or contracting, and on a monthly ongoing basis thereafter, to assure that employees and contractors are not excluded from receiving federal funds as required by 42 U.S.C. 1320a-7 and 42 U.S.C. 1320c-5((.));

(h) Report immediately to the ((department)) agency any information discovered regarding an employee's or contractor's exclusion from receiving federal funds in accordance with 42 U.S.C. 1320a-7 and 42 U.S.C. 1320c-5. See WAC ((388-502-0010)) 182-502-0010 (2)(j);

(i) Pass ((a background check, when the department requires such information to fully evaluate)) any portion of the agency's screening process as specified in WAC 182-502-0010 (2)(j) when the agency requires such information to reassess a provider;

(j) Maintain professional and general liability coverage requirements, if not covered under agency, center, or facility, in the amounts identified by the ((department)) medicaid agency;

(k) Not surrender, voluntarily or involuntarily, his or her professional state license, registration, or certification in any state while under investigation by that state or due to findings by that state resulting from the practitioner's acts, omissions, or conduct; ((and))

(l) Furnish documentation or other assurances as determined by the ((department)) agency in cases where a provider has an alcohol or chemical dependency problem, to adequately safeguard the health and safety of medical assistance clients that the provider:

(i) Is complying with all conditions, limitations, or restrictions to the provider's practice both public and private; and

(ii) Is receiving treatment adequate to ensure that the dependency problem will not affect the quality of the provider's practice; and

(m) Submit to a revalidation process at least every five years. This process includes, but is not limited to:

(i) Updating provider information including, but not limited to, disclosures;

(ii) Submitting forms as required by the agency including, but not limited to, a new core provider agreement; and

(iii) Passing the agency's screening process as specified in WAC 182-502-0010 (2)(j).

(2) A provider may contact the ((department)) agency with questions regarding its programs. However, the ((department's)) agency's response is based solely on the information provided to the ((department's)) agency's representative at the time of inquiry, and in no way exempts a provider from following the laws and rules that govern the ((department's)) agency's programs.

(3) The ((department)) agency may refer the provider to the appropriate state health professions quality assurance commission.

[11-14-075, recodified as 182-502-0016, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. 11-11-017, 388-502-0016, filed 5/9/11, effective 6/9/11.]

OTS-5188.1


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

WAC 182-502-0020   Health care record requirements.   This section applies to providers, as defined under WAC ((388-500-0005)) 182-500-0085 and under WAC ((388-538-050)) 182-538-050. Providers must:

(1) Maintain documentation in the client's medical or health care records to verify the level, type, and extent of services provided to each client to fully justify the services and billing, including, but not limited to:

(a) Client's name and date of birth;

(b) Dates of services;

(c) Name and title of person performing the service;

(d) Chief complaint or reason for each visit;

(e) Pertinent past and present medical history;

(f) Pertinent findings on examination at each visit;

(g) Medication(s) or treatment prescribed and/or administered;

(h) Name and title of individual prescribing or administering medication(s);

(i) Equipment and/or supplies prescribed or provided;

(j) Name and title of individual prescribing or providing equipment and/or supplies;

(k) Detailed description of treatment provided;

(l) Subjective and objective findings;

(m) Clinical assessment and diagnosis;

(n) Recommendations for additional treatments, procedures, or consultations;

(o) Radiographs (X rays), diagnostic tests and results;

(p) Plan of treatment and/or care, and outcome;

(q) Specific claims and payments received for services;

(r) Correspondence pertaining to client dismissal or termination of health care practitioner/patient relationship;

(s) Advance directives, when required under WAC ((388-501-0125)) 182-501-0125;

(t) Patient treatment agreements (examples: Opioid agreement, medication and treatment compliance agreements); and

(u) Informed consent documentation.

(2) Keep legible, accurate, and complete charts and records;

(3) Meet any additional record requirements of the department of health (DOH);

(4) Assure charts are authenticated by the person who gave the order, provided the care, or performed the observation, examination, assessment, treatment or other service to which the entry pertains;

(5) Make charts and records available to the ((department)) medicaid agency, its contractors or designees, and the United States Department of Health and Human Services (DHHS) upon request, for six years from the date of service or longer if required specifically by federal or state law or regulation. The ((department)) agency does not separately reimburse for copying of health care records, reports, client charts and/or radiographs, and related copying expenses; and

(6) Permit the ((department)) agency, DHHS, and its agents or designated contractors, access to its physical facilities and its records to enable the ((department)) agency and DHHS to conduct audits, inspections, or reviews without prior announcement.

[11-14-075, recodified as 182-502-0020, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. 11-11-017, 388-502-0020, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 74.09.530. 01-07-076, 388-502-0020, filed 3/20/01, effective 4/20/01; 00-15-050, 388-502-0020, filed 7/17/00, effective 8/17/00.]