WSR 16-01-204 PERMANENT RULES HEALTH CARE AUTHORITY (Washington Apple Health) [Filed December 23, 2015, 11:20 a.m., effective January 23, 2016] Effective Date of Rule: Thirty-one days after filing.
Purpose: The agency is striking WAC 182-550-4690 (3)(b), which states the agency performs utilization reviews on seven-day readmissions for claims that qualified for diagnosis related group payment before July 1, 2005.
The agency is also striking subsection (5)(c), which refers to WAC 182-550-3000 for inpatient hospital claims that involve a client's seven-day readmission.
This amendment aligns with amendments proposed under WSR 15-19-159, which will implement a population-based, data-driven approach to reduce hospital readmission rates and related costs.
Citation of Existing Rules Affected by this Order: Amending WAC 182-550-4690.
Adopted under notice filed as WSR 15-23-060 on November 13, 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Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.
Date Adopted: December 23, 2015.
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 15-18-065, filed 8/27/15, effective 9/27/15)
WAC 182-550-4690 Authorization requirements and utilization review for hospitals eligible for CPE payments.
This section does not apply to psychiatric certified public expenditure (CPE) inpatient hospital admissions. See WAC 182-550-2600.
(1) CPE inpatient hospital claims submitted to the medicaid agency must meet all authorization and program requirements in WAC and current agency-published issuances.
(2) The agency performs utilization reviews of inpatient hospital:
(a) Admissions under the requirements of 42 C.F.R. 456, subparts A through C; and
(b) Claims for compliance with medical necessity, appropriate level of care and the agency's (or an agency designee's) established length of stay (LOS) standards.
(3) For CPE inpatient admissions before August 1, 2007, the agency performs utilization reviews((:
(a))) using the professional activity study (PAS) length of stay (LOS) standard in WAC 182-550-4300 on claims that qualified for ratio of costs-to-charges (RCC) payment before July 1, 2005.
(((b) On seven-day readmissions according to the diagnosis related group (DRG) payment method described in WAC 182-550-3000 for claims that qualified for DRG payment before July 1, 2005.))
(4) For claims identified in this subsection, the agency may request a copy of the client's hospital medical records and itemized billing statements. The agency sends written notification to the hospital detailing the agency's findings. Any day of a client's hospital stay that exceeds the LOS standard:
(a) Is paid under a non-DRG payment method if the agency determines it to be medically necessary for the client at the acute level of care;
(b) Is paid as an administrative day (see WAC 182-550-1050 and 182-550-4500(8)) if the agency determines it to be medically necessary for the client at the subacute level of care; and
(c) Is not eligible for payment if the agency determines it was not medically necessary.
(5) For CPE inpatient admissions after July 31, 2007, CPE hospital claims are subject to the same utilization review rules as non-CPE hospital claims.
(a) LOS reviews may be performed under WAC 182-550-4300.
(b) All claims are subject to the agency's medical necessity review under WAC 182-550-1700(2).
(((c) For inpatient hospital claims that involve a client's seven-day readmission, see WAC 182-550-3000.))
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