WSR 14-21-180
(Washington Apple Health)
[Filed October 22, 2014, 10:38 a.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 13-15-177.
Title of Rule and Other Identifying Information: WAC 182-502-0230 Provider payment reviews and dispute rights.
Hearing Location(s): Health Care Authority (HCA), Cherry Street Plaza Building, Sue Crystal Conference Room 106A, 626 8th Avenue, Olympia, WA 98504 (metered public parking is available street side around building. A map is available at or directions can be obtained by calling (360) 725-1000), on November 25, 2014, at 10:00 a.m.
Date of Intended Adoption: Not sooner than November 26, 2014.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 45504, Olympia, WA 98504-5504, delivery 626 8th Avenue, Olympia, WA 98504, e-mail, fax (360) 586-9727, by 5:00 p.m. on November 25, 2014.
Assistance for Persons with Disabilities: Contact Kelly Richters by November 17, 2014, TTY (800) 848-5429, or (360) 725-1307, or e-mail
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: Revising and clarifying provider overpayment dispute policy.
Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Kevin Sullivan, P.O. Box 42716, Olympia, WA 98504-2716, (360) 725-1344; Implementation and Enforcement: Evelyn Cantrell, P.O. Box 45503, Olympia, WA 98504-5504, (360) 725-9970.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The joint administrative rules review committee has not requested the filing of a small business economic impact statement, and these rules do not impose a disproportionate cost impact on small businesses.
A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to HCA rules unless requested by the joint administrative rules review committee or applied voluntarily.
October 22, 2014
Kevin M. Sullivan
Rules Coordinator
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-502-0230 Provider ((payment reviews and dispute rights)) overpayment disputesGeneral.
(((1) As authorized by chapters 43.20B and 74.09 RCW, the department monitors and reviews all providers who furnish health care services to eligible clients. For the purposes of this section, health care services includes treatment, equipment, related supplies, and drugs. The department may review all documentation and/or data related to payments made to providers for health care services for eligible clients and determine whether the providers are complying with the rules and regulations of the program(s). Examples of provider reviews are:
(a) A review of all records and/or payments for medical assistance clients;
(b) A random sampling of billing and/or records for medical assistance clients; and/or
(c) A review focused on selected records for medical assistance clients.)) (1) This section applies to provider overpayment disputes with providers who furnish health care services to Washington apple health clients, except those overpayment disputes to which chapter 182-502A WAC applies. For the purposes of this section:
(a) "Agency" means the health care authority and its designees.
(b) "Provider" has the same meaning as vendor in RCW 41.05A.010(5).
(2) ((The department may)) If the medicaid agency determines that a ((provider's billing does not comply with program rules and regulations. As a result of that determination)) provider was overpaid, the ((department)) agency may take any of the following actions((, or others as appropriate)):
(a) ((Conduct prepay reviews of all claims the provider submits to the department)) Review claims, encounters, or payments;
(b) Refer the provider to the ((department's auditors (see chapter 388-502A WAC))) agency's office of program integrity;
(c) Refer the provider to the Washington state medicaid fraud control unit;
(d) Refer the provider to the appropriate state health ((professions quality assurance commission)) care professional discipline authority;
(e) Terminate the provider's participation in ((medical assistance programs (see WAC 388-502-0030))) Washington apple health;
(f) Assess a civil penalty against the provider, per RCW 74.09.210; ((and))
(g) In the event of a prepay review, suspend some or all payments;
(h) Adjust or void an improper claim, encounter, or payment;
(i) Recover any moneys that the provider received as a result of overpayments as authorized under chapter ((43.20B)) 41.05A RCW; and
(j) Any other action authorized by Title 182 WAC.
(3) A provider ((who disagrees with a department action regarding overpayment recovery)) may ((request)) contest an overpayment by requesting a hearing ((to dispute the action(s) per RCW 43.20B.675)).
(((a))) (4) The hearing request ((for hearing)) must:
(a) Be in writing; ((and
(i) Must be received by the department within twenty-eight days of the date of the notice of action(s), by certified mail (return receipt) or other means that provides proof of delivery to:
Office of Financial Recovery
P.O. Box 9501
Olympia, WA 98507-5501; and
(ii) State the reason(s) why the provider thinks the action(s) are incorrect.
(b) The office of administrative hearings schedules and conducts the hearing under the Washington Administrative Procedure Act, chapter 34.05 RCW, and chapter 388-02 WAC. The department offers a prehearing/alternative dispute conference prior to the hearing.
(c) The office of financial recovery collects any amount the provider is ordered to repay.))
(b) Identify each overpayment being contested;
(c) State each reason why the provider thinks the overpayment is incorrect;
(d) Include documentation to support the provider's position; and
(e) Include a copy of the overpayment notice.
(5) The hearing request must be served on the agency at the address specified in the overpayment notice, in a manner which provides proof of receipt, no later than twenty-eight calendar days after the provider received the overpayment notice.
(6) The hearing is conducted under the Administrative Procedure Act and chapter 182-526 WAC.