HEALTH CARE AUTHORITY

(Washington Apple Health)

(1) A provider must notify the ((department)) medicaid agency in writing within seven calendar days of ownership or control changes of any kind. An entity is considered to have an ownership or control interest in another entity if it has direct or indirect ownership of five percent or more, or is a managing employee (e.g., a general manager, business manager, administrator, or director) who exercises operational or managerial control over the entity or who directly or indirectly conducts day-to-day operations of the entity. The ((department)) agency determines whether a new core provider agreement (CPA) must be completed for the new entity.

(2) When a provider obtains a new federal tax identification (ID) following a change of ownership, the ((department)) agency terminates the provider's CPA as of the date of the change in federal tax ID. The provider may reapply for a new CPA.

(3) All new ownership enrollments are subject to the requirements in WAC ((388-502-0010)) 182-502-0010. In addition to those requirements, the applicant must:

(a) Complete a change of ownership form;

(b) Provide the ((department)) agency with a copy of the contract of sale identifying previous and current owners; and

(c) Provide the ((department)) agency with a list of all provider numbers affected by the change of ownership.

The purpose of this section is to establish the medicaid electronic health records (EHR) incentive program ((in accordance with)) under the American Recovery and Reinvestment Act of 2009 (ARRA). The medicaid EHR incentive program promotes the adoption and meaningful use of certified EHR technology by offering financial incentives to eligible professionals and hospitals. This program is administered by the ((department)) medicaid agency.

(1) The ((department)) agency provides incentive payments to eligible providers and hospitals that adopt and meaningfully use certified EHR technology ((in accordance with the provisions of)) under 42 C.F.R. Parts 412, 413, 422, and any other federal regulations that apply.

(2) Providers and hospitals eligible to participate in EHR incentive program are identified in 42 C.F.R. Part 495.304 and other applicable rules.

(3) As authorized by 42 C.F.R. Parts 412, 413, 422, chapters 43.20B and 74.09 RCW, and any other federal or state rules that apply, the ((department)) agency monitors and reviews all providers and hospitals participating in the EHR incentive program. By the same authority, the ((department)) agency reviews all practices, documentation, and((/or)) data related to EHR technology to determine whether professionals and hospitals participating in the EHR incentive program are eligible and complying with state and federal rules and regulations.

(4) The ((department)) agency may determine that a participating professional or hospital has not met the eligibility or performance requirements to receive an EHR incentive payment, or should receive an incentive payment in an amount less than the amount anticipated by the provider or hospital. Areas of possible dispute in the EHR incentive program include, at a minimum, any of the following:

(a) Patient volume thresholds and calculations, as outlined in 42 C.F.R. Parts 495.304 and 495.306.

(b) Eligibility criteria and payment limitations, as outlined in 42 C.F.R. Parts 495.10, 495.304, 495.306, and 495.310.

(c) Attestations and compliance demonstrations including, at a minimum:

(i) Attestations that certified EHR technology has been adopted, implemented, or upgraded; and

(ii) Demonstrations of meaningful use, as outlined in 42 C.F.R. Parts 495.6, 495.8, 495.306, 495.310, and in any future published federal regulations and requirements, as applicable.

(d) The payment process and incentive payment amounts, as outlined in 42 C.F.R. Parts 495.310, 495.312, and 495.314.

(e) Additional issues regarding EHR incentive program eligibility, participation, documentation, and compliance as outlined in 42 C.F.R. Parts 412, 413, 422 ((et al.)), and in any future published federal regulations and requirements, as applicable.

(5) All matters of dispute are subject to the Administrative Procedure Act (APA) appeal process ((per)) under chapter 34.05 RCW. A provider who disagrees with ((a department)) an agency action under this section may request a hearing. The hearing request must:

(a) Be in writing;

(b) Be received by the agency, at the address identified in the notice of action, within twenty-eight days of the date of the notice of action by certified mail (return receipt); and

(c) State the reason(((s))) or reasons why the provider thinks the action is incorrect.

(1) The ((department)) medicaid agency may immediately terminate a provider's core provider agreement (CPA) for any one or more of the following reasons, each of which constitutes cause:

(a) Provider exhibits significant risk factors that endanger client health ((and/))or safety. These factors include, but are not limited to:

(i) Moral turpitude;

(ii) Sexual misconduct as defined in WAC 246-934-100 or in profession specific rules of the department of health (DOH);

(iii) A statement of allegations or statement of charges by DOH;

(iv) Restrictions placed by DOH on provider's current practice such as chaperone required for rendering treatment, preceptor required to review practice, or prescriptive limitations;

(v) Limitations, restrictions, or loss of hospital privileges or participation in any health care plan ((and/))or failure to disclose the reasons to the ((department)) agency;

(vi) Negligence, incompetence, inadequate or inappropriate treatment, or lack of appropriate follow-up treatment;

(vii) Patient drug mismanagement ((and/or)), failure to identify substance abuse((/)) or addiction, or failure to refer the patient for substance abuse treatment once abuse((/)) or addiction is identified;

(viii) Use of health care providers or health care staff who are unlicensed to practice or who provide health care services ((which)) that are outside their recognized scope of practice or the standard of practice in the state of Washington;

(ix) Failure of the health care provider to comply with the requirements of WAC ((388-502-0016)) 182-502-0016;

(x) Failure of the health care practitioner with an alcohol or chemical dependency to furnish documentation or other assurances as determined by the ((department)) agency to adequately safeguard the health and safety of ((medical assistance)) Washington apple health clients that the provider:

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

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

(xi) Infection control deficiencies;

(xii) Failure to maintain adequate professional malpractice coverage;

(xiii) Medical malpractice claims or professional liability claims that constitute a pattern of questionable or inadequate treatment, or contain any gross or flagrant incident of malpractice; or

(xiv) Any other act ((which)) that the ((department)) agency determines is contrary to the health and safety of its clients.

(b) Provider exhibits significant risk factors that affect the provider's credibility or honesty. These factors include, but are not limited to:

(i) Failure to meet the requirements in WAC ((388-502-0010 and WAC 388-502-0020)) 182-502-0010 and 182-502-0020;

(ii) Dishonesty or other unprofessional conduct;

(iii) Investigatory (e.g., audit), civil, or criminal finding of fraudulent or abusive billing practices;

(iv) Exclusion from participation in medicare, medicaid, or any other federally((-)) funded health care program;

(v) Any conviction, no contest plea, or guilty plea relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct;

(vi) Any conviction, no contest plea, or guilty plea of a criminal offense;

(vii) Failure to comply with a DOH request for information or an ((on-going)) ongoing DOH investigation;

(viii) Noncompliance with a DOH or other state health care agency's stipulation to disposition, agreed order, final order, or other similar licensure restriction;

(ix) Misrepresentation or failure to disclose information on the enrollment application for a core provider agreement (CPA), failure to supply requested information, or failure to update CPA as required;

(x) Failure to comply with ((a department)) an agency request for information;

(xi) Failure to cooperate with ((a department)) an agency investigation, audit, or review;

(xii) Providing health care services ((which)) that are outside the provider's recognized scope of practice or the standard of practice in the state of Washington;

(xiii) Unnecessary medical((/)), dental, or other health care procedures;

(xiv) Discriminating in the furnishing of health care services, supplies, or equipment as prohibited by 42 U.S.C. § 2000d; and

(xv) Any other dishonest or discreditable act ((which)) that the ((department)) agency determines is contrary to the interest of the ((department)) agency or its clients.

(2) If a provider is terminated for cause, the ((department)) agency pays for authorized services provided up to the date of termination only.

(3) If the ((department)) agency terminates a provider who is also a full or partial owner of a group practice, the ((department)) agency also terminates all providers linked to the group practice. The remaining practitioners in the group practice may reapply for participation with the ((department)) agency subject to WAC ((388-502-0010(2))) 182-502-0010(2).

(4) A provider who is terminated for cause may dispute ((a department)) an agency decision under the process in WAC ((388-502-0050)) 182-502-0050.

(1) The ((department)) medicaid agency reimburses for medical services furnished to an eligible client when all ((of)) the following apply:

(a) The service is within the scope of care of the client's ((medical assistance)) Washington apple health 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)) 182-502-0150;

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

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

(2) The ((department)) agency 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)) agency does not reimburse providers for medical services identified by the ((department)) agency 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))) (copays) (unless the criteria in chapter ((388-517)) 182-517 WAC or WAC ((388-501-0200)) 182-501-0200 are met);

(b) Deductibles (unless the criteria in chapter ((388-517)) 182-517 WAC or WAC ((388-501-0200)) 182-501-0200 are met)((;

(c) Emergency medical expense requirements (EMER) (see WAC 388-550-1050 and 388-865-0217))); and

(((d))) (c) Spenddown (see WAC ((388-519-0110)) 182-519-0110).

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

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

(6) The ((department)) agency 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)) when it was provided if:

(a) The ((department)) agency 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)) agency.

(7) The ((department)) agency 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)) agency.

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

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

(1) The ((department)) medicaid agency pays for health care services provided outside the state of Washington only when the service meets the provisions ((set forth)) described in WAC ((388-501-0180, 388-501-0182, 388-501-0184)) 182-501-0180, 182-501-0182, 182-501-0184, and specific program WAC.

(2) With the exception of hospital services and nursing facilities, the ((department)) agency 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)) 182-501-0175).

(3) With the exception of designated bordering cities, the ((department)) agency does not pay for health care 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)) agency pays for health care 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)) apple health programs.

(5) The ((department)) agency 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)) under WAC 182-550-3900, 182-550-4000, 182-550-4800, and 182-550-6700.

(6) The ((department)) agency pays nursing facilities located outside the state of Washington when approved by the aging and ((disability services administration (ADSA))) long-term support administration (ALTSA) 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)) ALTSA.

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

(a) Have a signed agreement with the ((department)) agency;

(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)) 182-502-0100 and 182-502-0150;

(d) Satisfy all medicaid conditions of participation;

(e) Accept the ((department's)) agency's payment as payment in full according to 42 C.F.R. 447.15; and

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

(8) For covered services for eligible clients, the ((department)) agency 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.

(1) Providers who are enrolled as contractors with the ((department's)) medicaid agency's medical care programs may be assessed interest on excess benefits or other inappropriate payments. Nursing home providers are governed by WAC 388-96-310 and are not subject to this section.

(2) The ((department)) agency assesses interest when:

(a) The excess benefits or other inappropriate payments were not the result of ((department)) agency error; and

(b) A provider is found liable for receipt of excess benefits or other payments under RCW 74.09.220; or

(c) A provider is notified by the ((department)) agency that repayment of excess benefits or other payments is due under RCW 74.09.220.

(3) The ((department)) agency assesses interest at the rate of one percent for each month the overpayment is not satisfied. Daily interest calculations and assessments are made for partial months.

(4) Interest is calculated beginning from the date the ((department)) agency receives payment from the provider. Interest ceases to be calculated and collected from the provider once the overpayment amount is received by the ((department)) agency.

(5) The ((department)) agency calculates interest and amounts, which are identified on all ((department)) agency collection notices and statements.

Providers must bill the ((department)) medicaid agency for covered services provided to eligible clients as follows:

(1) The ((department)) agency requires providers to submit initial claims and adjust prior claims in a timely manner. The ((department)) agency 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)) agency as described in the ((department's)) agency's current published billing instructions.

(3) Providers must submit the initial claim to the ((department)) agency and have a transaction control number (TCN) assigned by the ((department)) agency 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)) agency to cover the service; or

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

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

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

(5) The ((department)) agency requires providers to bill known third parties for services. See WAC ((388-501-0200)) 182-501-0200 for exceptions. Providers must meet the timely billing standards of the liable third parties in addition to the ((department's)) agency'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)) agency. If medicare:

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

(b) Denies payment of the claim, the ((department)) agency 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 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))) (8) After twenty-four months from the date the service was provided to the client, the ((department)) agency 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)) agency by a negotiable financial instrument, such as a bank check.

(9) The ((department)) agency allows providers to resubmit, modify, or adjust any prescription drug claim with a timely TCN within fifteen months of the date the service was provided to the client. After fifteen months, the ((department)) agency 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)) agency. After fifteen months a provider must refund overpayments by a negotiable financial instrument, such as a bank check.

(11) The ((department)) agency 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)) 182-531-2000 (for physician claims) or WAC ((388-550-5450)) 182-550-5450 (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)) agency. A provider must refund an overpayment for a trauma claim that received payment from TCF using a method specified by the ((department)) agency.

(13) If a provider fails to bill a claim according to the requirements of this section and the ((department)) agency 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.

(1) At the request of the ((department)) medicaid agency, all providers enrolled with ((department)) agency programs must submit full reports, as specified by the ((department)) agency, of goods and services furnished to eligible ((medical assistance)) Washington apple health clients. The ((department)) agency furnishes the provider with a standardized format to report these data.

(2) The ((department)) agency 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 the ((department's)) agency's advisory committee, the state welfare medical care committee, representative organizations of provider groups enrolled with the ((department)) agency, and any other interested organizations or individuals.

(1) Providers of medical services who have a contract, other than a core provider agreement, with a dispute resolution provision must follow the dispute resolution process described in the contract.

(2) See WAC ((388-502-0220)) 182-502-0220 for disputes involving rates. See chapter 182-502A WAC ((388-502-0240)) for disputes involving audits. See WAC ((388-502-0230)) 182-502-0230 for disputes involving provider reviews and termination.

(1) Any enrolled contractor((/)) or provider of medical services has a right to an administrative appeal when the contractor((/)) or provider disagrees with the ((department)) medicaid agency reimbursement rate. The exception to this is nursing facilities governed by WAC 388-96-904.

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

(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 the ((department)) agency to recalculate the rate.

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

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

(i) Request additional information; and((/or))

(ii) Conduct an audit of the documentation provided.

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

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

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

(e) The ((department)) agency 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((/)) or provider must file the appeal within sixty calendar days of the date of the rate notification letter from the ((department)) agency. The ((department)) agency does not consider any appeal filed after the sixty-day period to be eligible for retroactive adjustment.

(f) The ((department)) agency may grant a time extension for the appeal period if the contractor((/)) or provider makes such a request within the sixty-day period ((referenced under)) described in (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)) agency.

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

(j) Any rate change that the ((department)) agency grants that is the result of fraudulent practices on the part of the contractor((/)) or 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((/)) or provider disagrees with a rate review decision, it may file a request for a dispute conference with the ((department)) agency. For this section "dispute conference" means an informal administrative hearing ((for the purpose of resolving)) to resolve contractor((/)) or provider disagreements with ((a department)) an agency 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((/)) or provider files a request for a dispute conference, it must submit the request to the ((department)) agency within thirty calendar days after the contractor((/)) or provider receives the rate review decision. The ((department)) agency does not consider dispute conference requests submitted after the thirty-day period for the first level decision.

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

(c) ((A department-appointed)) An agency-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)) agency and precedes judicial action.

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