WSR 15-17-066 PERMANENT RULES HEALTH CARE AUTHORITY (Washington Apple Health) [Filed August 14, 2015, 1:51 p.m., effective September 14, 2015] Effective Date of Rule: Thirty-one days after filing.
Purpose: To establish in rule the agency's policy for payment of services provided by, or in conjunction with, a resident physician.
Citation of Existing Rules Affected by this Order: Amending WAC 182-531-0250 and 182-531-1900.
Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.
Adopted under notice filed as WSR 15-14-071 on June 26, 2015.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 2, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 2, Repealed 0.
Date Adopted: August 14, 2015.
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 15-03-041, filed 1/12/15, effective 2/12/15)
WAC 182-531-0250 Who can provide and bill for physician-related and health care professional services.
(1) The health care professionals and health care entities listed in WAC 182-502-0002 and enrolled with the medicaid agency can bill for physician-related and health care professional services that are within their scope of practice.
(2) The agency pays for services provided by, or in conjunction with, a resident physician when:
(a) The services are billed under the teaching hospital's national provider identifier (NPI) or the supervising physician's NPI;
(b) The performing provider is identified on the claim under the teaching or resident physician's NPI; and
(c) The services are provided and billed according to this chapter and chapters 182-501 and 182-502 WAC.
(3) The agency does not pay for services performed by any of the health care professionals listed in WAC 182-502-0003.
(((3))) (4) The agency pays eligible providers for physician-related services and health care professional services if those services are mandated by, and provided to((,)) clients who are eligible for, one of the following:
(a) The early and periodic screening, diagnosis, and treatment (EPSDT) program;
(b) A Washington apple health program for qualified medicare beneficiaries (QMB); or
(c) A waiver program.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-531-1900 ((Reimbursement)) Payment—General requirements for physician-related services.
(1) The ((department reimburses)) medicaid agency pays physicians and related providers for covered services provided to eligible clients on a fee-for-service basis, subject to the exceptions, restrictions, and other limitations listed in this chapter and other published issuances.
(2) ((In order to be reimbursed)) To receive payment, physicians must bill the ((department)) agency according to the conditions of payment under WAC ((388-501-0150 and other issuances)) 182-502-0100.
(3) The ((department)) agency does not separately reimburse certain administrative costs or services. The ((department)) agency considers these costs to be included in the ((reimbursement)) payment. These costs and services include the following:
(a) Delinquent payment fees;
(b) Educational supplies;
(c) Mileage;
(d) Missed or canceled appointments;
(e) Reports, client charts, insurance forms, and copying expenses;
(f) Service charges;
(g) Take home drugs; and
(h) Telephoning (e.g., for prescription refills).
(4) The ((department)) agency does not routinely pay for procedure codes which have a "#" or "NC" indicator in the fee schedule. The ((department)) agency reviews these codes for conformance to medicaid program policy only as an exception to policy or as a limitation extension. See WAC ((388-501-0160 and 388-501-0165)) 182-501-0160 and 182-501-0165.
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