Effective Date of Rule: May 1, 2013.

     Purpose: These rules establish the medicaid agency's authority to designate willing providers as nonbilling providers and establish the rules applicable to those providers who may apply for this new designation. Nonbilling providers are health care professionals who wish to enroll with the agency to only be an ordering, referring, prescribing provider for the Washington medicaid program and who is not otherwise enrolled as a medicaid provider with the agency. This is required for medicaid to be compliant with the Affordable Care Act, while retaining access to clients for providers who qualify for this designation.

     Citation of Existing Rules Affected by this Order: Amending WAC 182-500-0075, 182-500-0080, 182-500-0085, 182-502-0005, and 182-530-1000.

     Statutory Authority for Adoption: RCW 41.05.021.

     Under RCW 34.05.350 the agency for good cause finds that immediate adoption, amendment, or repeal of a rule is necessary for the preservation of the public health, safety, or general welfare, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the public interest; and that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule.

     Reasons for this Finding: Client's access to services ordered, prescribed or referred by providers who would qualify as nonbilling would be adversely affected and consequently their health status may be compromised, as these services include diagnostics, admissions and medication. If the service ordered were a mental health medication public safety could be compromised.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 1, Amended 5, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 5, Repealed 0.

     Date Adopted: April 30, 2013.

Kevin M. Sullivan

Rules Coordinator

OTS-5421.1

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

WAC 182-500-0075   Medical assistance definitions -- N.   "National correct coding initiative (NCCI)" is a national standard for the accurate and consistent description of medical goods and services using procedural codes. The standard is based on coding conventions defined in the American Medical Association's Current Procedural Terminology (CPT¦) manual, current standards of medical and surgical coding practice, input from specialty societies, and analysis of current coding practices. The Centers for Medicare and Medicaid Services (CMS) maintain NCCI policy. Information can be found at: http://www.cms.hhs.gov/NationalCorrectCodInitEd/.

     "National provider indicator (NPI)" is a federal system for uniquely identifying all providers of health care services, supplies, and equipment.

     "NCCI edit" is a software step used to determine if a claim is billing for a service that is not in accordance with federal and state statutes, federal and state regulations, agency or the agency's designee's fee schedules, billing instructions, and other publications. The agency or the agency's designee has the final decision whether the NCCI edits allow automated payment for services that were not billed in accordance with governing law, NCCI standards or agency or agency's designee policy.

     "Nonapplying spouse" see "spouse" in WAC ((388-500-0100)) 182-500-0100.

     "Nonbilling provider" is a health care professional who wishes to enroll with the agency to only be an ordering, referring, prescribing provider for the Washington medicaid program and who is not otherwise enrolled as a medicaid provider with the agency.

     "Noncovered service" see "covered service" in WAC ((388-500-0020)) 182-500-0020.

     "Nursing facility" see "institution" in WAC ((388-500-0050)) 182-500-0050.

[11-14-075, recodified as § 182-500-0075, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. 11-14-053, § 388-500-0075, filed 6/29/11, effective 7/30/11.]

     "Outpatient" means a patient receiving care in a hospital outpatient setting or a hospital emergency department, or away from a hospital such as in a physician's office or clinic, the patient's own home, or a nursing facility.

     "Overhead costs" means those costs that have been incurred for common or joint objectives and cannot be readily identified with a particular final cost objective. Overhead costs that are allocated must be clearly distinguished from other functions and identified as a benefit to a direct service.

[11-14-075, recodified as § 182-500-0080, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. 11-14-053, § 388-500-0080, filed 6/29/11, effective 7/30/11.]

     "Physician" means a doctor of medicine, osteopathy, or podiatry who is legally authorized to perform the functions of the profession by the state in which the services are performed.

     "Prescribing provider" means physician or other professional authorized by law or rule to prescribe drugs for clients eligible for Washington's health care programs administered by the agency.

     "Prior authorization" is the requirement that a provider must request, on behalf of a client and when required by rule, the agency's or the agency's designee's approval to render a health care service or write a prescription in advance of the client receiving the health care service or prescribed drug, device, or drug-related supply. The agency's or the agency's designee's approval is based on medical necessity. Receipt of prior authorization does not guarantee payment. Expedited prior authorization and limitation extension are types of prior authorization.

     "Prosthetic devices" means replacement, corrective, or supportive devices prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice as defined by state law to:

•	Artificially replace a missing portion of the body;

•	Prevent or correct physical deformity or malfunction; or
•	Support a weak or deformed portion of the body.

     "Provider" means an institution, agency, or person that is licensed, certified, accredited, or registered according to Washington state laws and rules, and:

     (1) Has signed a core provider agreement or signed a contract with the agency or the agency's designee, and is authorized to provide health care, goods, and/or services to medical assistance clients; or

     (2) Has authorization from a managed care organization (MCO) that contracts with the agency or the agency's designee to provide health care, goods, and/or services to eligible medical assistance clients enrolled in the MCO plan.

     "Public institution" see "institution" in WAC ((388-500-0050)) 182-500-0050.

[11-14-075, recodified as § 182-500-0085, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15. 11-14-053, § 388-500-0085, filed 6/29/11, effective 7/30/11.]

OTS-5426.2

AMENDATORY SECTION(Amending WSR 12-12-032, filed 5/29/12, effective 7/1/12)

WAC 182-502-0005   Core provider agreement (CPA).   (1) The agency only pays claims submitted by or on behalf of a health care professional, health care entity, supplier or contractor of service that has an approved core provider agreement (CPA) with the agency ((or)), is a performing provider on an approved CPA with the agency, or has an approved agreement with the agency as a nonbilling provider in accordance with WAC 182-502-0006.

     (2) 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. Refer to WAC 182-502-0006 for enrollment as a nonbilling provider.

     (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 or application for nonbilling provider 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.

[Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455 subpart E Provider Screening and Enrollment requirements. 12-12-032, § 182-502-0005, filed 5/29/12, effective 7/1/12. 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.]

     (a) Core provider agreement, in accordance with WAC 182-502-0005; or

     (b) Nonbilling provider agreement, in accordance with subsection (4) of this section.

     (2) Only a licensed health care professional whose scope of practice under their licensure includes ordering, prescribing, or referring may enroll as a nonbilling provider.

     (3) Nothing in this chapter obligates the agency to enroll any health care professional, who requests enrollment as a nonbilling provider.

     (4) Enrollment.

     (a) To enroll as a nonbilling provider with the medicaid agency, a health care professional must, on the date of application:

     (i) Not already be enrolled with the medicaid agency as a billing or servicing provider;

     (ii) Be currently licensed, certified, accredited, or registered according to Washington state laws and rules;

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

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

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

     (vi) 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;

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

     (viii) Sign, without modification, a Medicaid Enrollment Application and Agreement for Nonbilling Individual Providers form (HCA 13-002). The medicaid agency and each provider signing a Medicaid Enrollment Application and Agreement for Nonbilling Individual Providers form (HCA 13-002) will hold each other harmless from a legal action based on the negligent actions or omissions of either party under the terms of this agreement.

     (b) The medicaid agency does not enroll a nonbilling provider for reasons which include, but are not limited to, the following:

     (i) The agency determines that:

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

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

     (ii) The health care professional:

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

     (B) 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;

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

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

     (E) 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;

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

     (G) Fails a background check, including a fingerprint-based criminal background check, performed by the agency. See WAC 182-502-0014, except that subsection (2) of this section does not apply to nonbilling providers;

     (H) Does not have sufficient liability insurance according to (a)(i) of this subsection for the scope of practice; or

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

     (5) Effective date of enrollment of nonbilling provider. Enrollment of a nonbilling provider applicant is effective on the date the agency approves the nonbilling provider application.

     (a) A nonbilling provider applicant may ask for an effective date earlier than the agency's approval of the nonbilling 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 nonbilling 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.

     (6) Continuing requirements. To continue eligibility, a nonbilling provider must:

     (a) Only order, refer, or prescribe for clients consistent within the scope of their department of health (DOH) licensure and agency program rules;

     (b) 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;

     (c) Document that the client was informed that the provider:

     (i) May bill the client for any billable item or service. The rules in WAC 182-502-0160 do not apply; and

     (ii) Is enrolled with the agency for the sole purpose of ordering, prescribing, or referring items or services for clients.

     (d) Inform the agency of any changes to the provider's Medicaid Enrollment Application and Agreement for Nonbilling Individual Providers form (HCA 13-002) including, but not limited to, changes in:

     (i) Address or telephone number;

     (ii) Business name.

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

     (f) Inform the 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) Maintain professional liability coverage requirements;

     (h) 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;

     (i) Furnish documentation or other assurances as determined by the 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.

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

     (i) Updating provider information;

     (ii) Submitting forms as required by the agency including, but not limited to, a new Medicaid Enrollment Application and Agreement for Nonbilling Individual Providers form (HCA 13-002); and

     (iii) Passing the agency's screening process as specified in subsection (4)(a)(vi) of this section.

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

     (7) Audit or investigation.

     (a) Audits or investigations may be conducted to determine compliance with the rule and regulations of the program.

     (b) If an audit or investigation is initiated, the provider must retain all original records and supportive materials until the audit is completed and all issues are resolved even if the period of retention extends beyond the required six year period.

     (8) Inspection; maintenance of records. For six years from the date of services, or longer if required specifically by law, the nonbilling provider must:

     (a) Keep complete and accurate medical records that fully justify and disclose the extent of the services or items ordered, referred or prescribed.

     (b) Make available upon request appropriate documentation, including client records, supporting material for review by the professional staff within the agency or the U.S. Department of Health and Human Services. The nonbilling provider understands that failure to submit or failure to retain adequate documentation may result in the termination of the nonbilling provider's enrollment.

     (9) Terminations.

     (a) The agency may immediately terminate a nonbilling provider's agreement, and refer the nonbilling provider to the appropriate state health professions quality assurance commission for:

     (i) Any of the reasons in WAC 182-502-0030 termination for cause (except that subsection (1)(a)(ix) and (b)(i) do not apply); and

     (ii) Failure to comply with the requirements of subsections (4), (6), and (8) of this section.

     (b) Either the agency or the provider may terminate this agreement for convenience at any time with thirty calendar days' written notification to the other.

     (c) If this agreement is terminated for any reason, the agency will pay for services ordered, referred, or prescribed by the provider only through the date of termination.

     (10) Termination disputes.

     (a) To dispute terminations of a nonbilling provider agreement under subsection (9)(a) of this section, the dispute process in WAC 182-502-0050 applies.

     (b) Nonbilling providers cannot dispute terminations under subsection (9)(b) of this section.

[]

OTS-5420.1

AMENDATORY SECTION(Amending WSR 13-04-095, filed 2/6/13, effective 3/9/13)

WAC 182-530-1000   Outpatient drug program--General.   (1) The purpose of the outpatient drug program is to reimburse providers for outpatient drugs, vitamins, minerals, devices, and drug-related supplies according to medicaid agency rules and subject to the limitations and requirements in this chapter.

     (2) The agency reimburses for outpatient drugs, vitamins, minerals, devices, and pharmaceutical supplies that are:

     (a) Covered. Refer to WAC 182-530-2000 for covered drugs, vitamins, minerals, devices, and drug-related supplies and to WAC 182-530-2100 for noncovered drugs and drug-related supplies;

     (b) Prescribed by a provider with prescriptive authority (see exceptions for family planning and emergency contraception for women eighteen years of age and older in WAC 182-530-2000 (1)(b), and over-the-counter (OTC) drugs to promote smoking cessation in WAC 182-530-2000 (1)(g);

     (c) Prescribed by:

     (i) A provider with an approved core provider agreement; ((or))

     (ii) A provider who is enrolled as a performing provider on an approved core provider agreement; or

     (iii) A provider who is enrolled as a nonbilling provider.

     (d) Within the scope of an eligible client's medical assistance program;

     (e) Medically necessary as defined in WAC 182-500-0070 and determined according to the process found in WAC 182-501-0165;

     (f) Authorized, as required within this chapter;

     (g) Billed according to WAC 182-502-0150 and 182-502-0160; and

     (h) Billed according to the requirements of this chapter.

     (3) Coverage determinations for the agency are made by the agency's pharmacists or medical consultants in accordance with applicable federal law. The agency's determination may include consultation with the drug use review (DUR) board.

[Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455.410. 13-04-095, § 182-530-1000, filed 2/6/13, effective 3/9/13. 11-14-075, recodified as § 182-530-1000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 09-05-007, § 388-530-1000, filed 2/5/09, effective 3/8/09. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.700, 2008 c 245. 08-21-107, § 388-530-1000, filed 10/16/08, effective 11/16/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 07-20-049, § 388-530-1000, filed 9/26/07, effective 11/1/07; 06-24-036, § 388-530-1000, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.09.080, 74.04.050 and 42 C.F.R. Subpart K, subsection 162.1102. 02-17-023, § 388-530-1000, filed 8/9/02, effective 9/9/02. Statutory Authority: RCW 74.08.090, 74.04.050. 01-01-028, § 388-530-1000, filed 12/7/00, effective 1/7/01. Statutory Authority: RCW 74.08.090. 96-21-031, § 388-530-1000, filed 10/9/96, effective 11/9/96.]