HEALTH CARE AUTHORITY

(Washington Apple Health)

A client ((and/))or the client's provider may request that the medicaid agency or its designee ((to)) pay for a noncovered health care service. This is called an exception to rule (ETR). The request for ETR must be made before the service is rendered.

(1) The agency's medical director or designee evaluates and considers requests on a case-by-case basis. The agency's medical director has final authority to approve or deny a request for ETR.

(2) The agency or its designee cannot approve an ((exception to rule)) ETR if the requested service is excluded under state statute.

(((2) The)) (3) Any item or service(((s))) for which an ((exception)) ETR is requested must ((be of a type and nature which falls)):

(a) Fall within accepted standards and precepts of good medical practice;

(((3) All exception requests must)) (b) Represent cost-effective ((utilization of medical assistance program funds as determined by the agency or its designee;

(4) A request for an exception to rule must)) use of public funds; and

(c) Be submitted to the agency or its designee in writing within ninety days of the date of the written notification denying authorization for the noncovered service.

(4) For the agency or its designee to consider the ((exception to rule)) ETR request:

(a) The client ((and/))or the client's health care provider must submit sufficient client-specific information and documentation to the agency's medical director or designee which demonstrate that the client's clinical condition is so different from the majority that there is no equally effective, less costly covered service or equipment that meets the client's need(((s))).

(b) The client's health care ((professional)) provider must certify that medical treatment or items of service which are covered under the client's ((medical assistance)) Washington apple health program and which, under accepted standards of medical practice, are indicated as appropriate for the treatment of the illness or condition, have been found to be:

(i) Medically ineffective in the treatment of the client's condition; or

(ii) Inappropriate for that specific client.

(5) Within fifteen business days of receiving the request, the agency or its designee must send((s)) written notification to the provider and the client:

(a) Approving the ((exception to rule)) ETR request;

(b) Denying the ((exception to rule)) ETR request; or

(c) Requesting additional information.

(i) The additional information must be received by the agency or its designee within thirty days of the date the information was requested.

(ii) The agency or its designee must approve((s or denies the exception to rule)) or deny the ETR request within five business days of receiving the additional information.

(iii) If the requested information is insufficient or not provided within thirty days, the agency or its designee denies the ((exception to rule)) ETR request.

(6) ((The agency's medical director or designee evaluates and considers requests on a case-by-case basis. The agency's medical director has final authority or approve or deny a request for exception to rule.

(7) Clients do)) A client does not have a right to a fair hearing on ((exception to rule)) ETR decisions.