"Caretaker relative" means a relative of a dependent child by blood, adoption, or marriage with whom the child is living, who assumes primary responsibility for the child's care, and who is one of the following:

(((1)))(a) The child's father, mother, grandfather, grandmother, brother, sister, stepfather, stepmother, stepbrother, stepsister, uncle, aunt, first cousin, nephew, or niece.

(((2)))(b) The spouse of such parent or relative (including same sex marriage or domestic partner), even after the marriage is terminated by death or divorce.

(((3)))(c) Other relatives including relatives of half-blood, first cousins once removed, people of earlier generations (as shown by the prefixes of great, great-great, or great-great-great), and natural parents whose parental rights were terminated by a court order.

"Carrier" means an organization that contracts with the federal government to process claims under medicare Part B.

"Categorically needy (CN) or categorically needy program (CNP)" is the state and federally funded health care program established under Title XIX of the Social Security Act for people within medicaid-eligible categories, whose income and/or resources are at or below set standards.

"Categorically needy income level (CNIL)" is the standard used by the agency to determine eligibility under a categorically needy program.

"Categorically needy (CN) scope of care" is the range of health care services included within the scope of service categories described in WAC 182-501-0060 available to people eligible to receive benefits under a CN program. Some state-funded health care programs provide CN scope of care.

"Center of excellence" – A hospital, medical center, or other health care provider that meets or exceeds standards set by the agency for specific treatments or specialty care.

"Centers for Medicare and Medicaid Services (CMS)" - The federal agency that runs the medicare, medicaid, and children's health insurance programs, and the federally facilitated marketplace.

"Children's health program or children's health care programs" See "Apple health for kids."

"Client" means a person who is an applicant for, or recipient of, any Washington apple health program, including managed care and long-term care. See definitions for "applicant" and "recipient" in RCW 74.09.741.

"Community spouse." See "spouse" in WAC 182-500-0100.

"Cost-sharing" means any expenditure required by or on behalf of an enrollee with respect to essential health benefits; such term includes deductibles, coinsurance, copayments, or similar charges, but excludes premiums, balance billing amounts for nonnetwork providers, and spending for noncovered services.

"Cost-sharing reductions" means reductions in cost-sharing for an eligible person enrolled in a silver level plan in the health benefit exchange or for a person who is an American Indian or Alaska native enrolled in a qualified health plan (QHP) in the exchange.

"Couple." See "spouse" in WAC 182-500-0100.

"Covered service" is a health care service contained within a "service category" that is included in a Washington apple health (WAH) benefits package described in WAC 182-501-0060. For conditions of payment, see WAC 182-501-0050(5). A noncovered service is a specific health care service (for example, cosmetic surgery), contained within a service category that is included in a WAH benefits package, for which the agency or the agency's designee requires an approved exception to rule (ETR) (see WAC 182-501-0160). A noncovered service is not an excluded service (see WAC 182-501-0060).

"Creditable coverage" means most types of public and private health coverage, except Indian health services, that provide access to physicians, hospitals, laboratory services, and radiology services. This term applies to the coverage whether or not the coverage is equivalent to that offered under premium-based programs included in Washington apple health (WAH). Creditable coverage is described in 42 U.S.C. 300gg-3 (c)(1).

"Early and periodic screening, diagnosis and treatment (EPSDT)" is a comprehensive child health program that entitles infants, children, and youth to preventive care and treatment services. EPSDT is available to people age twenty and younger who are eligible for any agency health care program. Access and services for EPSDT are governed by federal rules at 42 C.F.R., Part 441, Subpart B. See chapter 182-534 WAC.

"Early elective delivery" means any nonmedically necessary induction or cesarean section before thirty-nine weeks of gestation. Thirty-nine weeks of gestation is greater than thirty-eight weeks and six days.

"Emergency medical condition" means the sudden onset of a medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

(((1)))(a) Placing the patient's health in serious jeopardy;

(((2)))(b) Serious impairment to bodily functions; or

(((3)))(c) Serious dysfunction of any bodily organ or part.

"Employer-sponsored dependent coverage" means creditable health coverage for dependents offered by a family member's employer or union, for which the employer or union may contribute in whole or in part towards the premium. Extensions of such coverage (e.g., COBRA extensions) also qualify as employer-sponsored dependent coverage as long as there remains a contribution toward the premiums by the employer or union.

"Evidence-based medicine (EBM)" means the application of a set of principles and a method for the review of well-designed studies and objective clinical data to determine the level of evidence that proves to the greatest extent possible, that a health care service is safe, effective, and beneficial when making:

(((1)))(a) Population-based health care coverage policies (WAC 182-501-0055 describes how the agency or its designee determines coverage of services for its health care programs by using evidence and criteria based on health technology assessments); and

(((2)))(b) Individual medical necessity decisions (WAC 182-501-0165 describes how the agency or its designee uses the best evidence available to determine if a service is medically necessary as defined in WAC 182-500-0030).

"Exception to rule." See WAC 182-501-0160 for exceptions to noncovered health care services, supplies, and equipment. See WAC 182-503-0090 for exceptions to program eligibility.

"Expedited prior authorization (EPA)" means the process for obtaining authorization for selected health care services in which providers use a set of numeric codes to indicate to the agency or the agency's designee which acceptable indications, conditions, or agency or agency's designee-defined criteria are applicable to a particular request for authorization. EPA is a form of "prior authorization."

"Extended care services" means nursing and rehabilitative care in a skilled nursing facility provided to a recently hospitalized medicare patient.

The medicaid agency pays contracted school districts, educational service districts, charter schools, and tribal schools for school-based health care services provided to medicaid-eligible children who require early intervention and special education services consistent with Sections 1903(c) and 1905(a) of the Social Security Act. The agency pays school districts through fee-for-service. Covered services must:

(1) Identify, treat, and manage the ((education-related)) disabilities (((i.e., mental, emotional, and physical))) of a child who requires early intervention and special education services;

(2) Be prescribed or recommended by licensed physicians or other licensed health care providers within their scope of practice under state law;

(3) Be medically necessary;

(4) ((Be diagnostic, evaluative, habilitative, or rehabilitative in nature;

(5))) Be included in the child's current individualized education program (IEP) or individualized family service plan (IFSP); and

(((6)))(5) Be provided in a school setting or by telemedicine.

The following definitions and those found in chapter 182-500 WAC apply to this chapter:

"Agency" - See WAC 182-500-0010.

"Assessment" - For the purposes of this chapter, an assessment is made-up of medically necessary tests given to an individual child by a licensed ((professional))health care provider to evaluate whether a child ((is determined to be a child)) with a disability((, and))is in need of early intervention services or special education and related services. Assessments are a part of the individualized education program (IEP) and individualized family service plan (IFSP) evaluation and ((re-evaluation))reevaluation processes ((and must accompany the individualized education program (IEP) or individualized family service plan (IFSP))).

"Child with a disability" - For purposes of this chapter, a child with a disability is a child evaluated and determined to need early intervention services or special education and related services because of a disability in one or more of the following eligibility categories:

• Autism;

• Deaf-blindness;

• Developmental delay for children ages three through nine, with an adverse educational impact, the results of which require special education and related direct services;

• Hearing loss (including deafness);

• Intellectual disability;

• Multiple disabilities;

• Orthopedic impairment;

• Other health impairment;

• Serious emotional disturbance (emotional behavioral disturbance);

• Specific learning disability;

• Speech or language impairment;

• Traumatic brain injury; and

• Visual impairment (including blindness).

"Early intervention services" - ((Services designed to meet the developmental needs of an infant or toddler with a disability and the needs of the family to assist appropriately in the infant's or toddler's development, as identified in the infant or toddler's individualized family service plan (IFSP), in any one or more of the following areas, including:

• Adaptive development.))Means developmental services provided to children ages birth through two. For the purposes of this chapter, early intervention services include:

"Electronic signature" - ((A signature in electronic form attached to or associated with an electronic record including, but not limited to, a digital signature.))See WAC 182-500-0030.

"Evaluation" - Procedures used to determine whether a child has a disability, and the nature and extent of the early intervention and special education and related services needed. (See WAC 392-172A-01070 and 34 C.F.R. Sec. 303.321.)

(("Evaluation report" - See WAC 392-172A-03035.))

"Fee-for-service" - See WAC 182-500-0035.

"Handwritten signature" - A scripted name or legal mark of an individual on a document to signify knowledge, approval, acceptance, or responsibility of the document.

"Health care-related services" - For the purposes of this chapter, means developmental, corrective, and other supportive services required to assist ((an eligible child to benefit from special education. For the purposes of the school-based health care services program, related services))a student eligible for special education and include:

• Audiology;

• Counseling;

• ((Nursing))School health services and school nurse services;

• Occupational therapy;

• Physical therapy;

• Psychological assessments and services; and

• Speech-language therapy.

"Individualized education program (IEP)" - A written educational program for a child who is age three through twenty and eligible for special education. An IEP is developed, reviewed and revised ((under))according to WAC 392-172A-03090 through ((392-172A-03135))392-172A-03115.

"Individualized family service plan (IFSP)" - A plan for providing early intervention services to a child birth through age two, with a disability or developmental delay and the child's family. The IFSP:

• Is based on the evaluation and assessment described in 34 C.F.R. Sec. 303.321;

• Includes the content specified in 34 C.F.R. Sec. 303.344((;

• Is implemented as soon as possible after parental consent is obtained for the early intervention services in the IFSP (consistent with 34 C.F.R. Sec. 303.420))); and

• Is developed under the IFSP procedures in 34 C.F.R. Secs. 303.342, 303.343, and 303.345.

"Medically necessary" - See WAC 182-500-0070.

"National provider identifier (NPI)" - See WAC 182-500-0075.

(("Qualified health care provider" - See WAC 182-537-0350.))

"Reevaluation" - Procedures used to determine whether a child continues to ((be in need of))need early intervention services or special education and related services. (See WAC 392-172A-03015 and 34 C.F.R. Secs. 303.342 and 303.343.)

"School-based health care services program" or "SBHS" - ((School-based health care services for infants and toddlers receiving early intervention services and children who require special education services, which are diagnostic, evaluative, habilitative, and rehabilitative in nature; are based on the child's medical needs; and are included in the child's IEP or IFSP. The agency pays school districts for school-based health care services delivered to medicaid-eligible children who require special education services under Section 1903(c) of the Social Security Act, and to people under the Individuals with Disabilities Education Act (IDEA) Part B and Part C.))Is an agency-administered program that pays contracted school districts, educational service districts (ESDs), charter schools, and tribal schools for providing early intervention services and special education health-related services to children ages birth through twenty who have an IEP or IFSP. Services must be provided by department of health (DOH)-licensed providers who are enrolled under the school district's ProviderOne account.

"Signature log" - A typed list that verifies a licensed provider's identity by associating each provider's signature with their name, handwritten initials, credentials, license and national provider ((identification (NPI) numbers))identifier (NPI).

"Special education" - ((Specially designed instruction, at no cost to the parents, to meet the unique needs of a student eligible for special education, including instruction conducted in the classroom, in the home, in hospitals and institutions, and in other settings, and instruction in physical education. Refer to))See WAC 392-172A-01175.

"Supervision" - Means supervision ((that is)) provided by a licensed health care provider either directly or indirectly ((in order)) to assist the supervisee in the administration of health care-related services outlined in the IEP or IFSP.

"Telemedicine" - See WAC 182-531-1730.

((Children who require special education services must be receiving Title XIX Medicaid under a Washington apple health (WAH) categorically needy program (CNP) or WAH medically needy program (MNP) to be eligible for school-based health care services. Eligible children enrolled in a managed care organization (MCO) receive school-based health care services on a fee-for-service basis.))(1) Contracted school districts may receive medicaid payment for students ages birth through twenty who:

(1) School-based health care services (SBHS) must be delivered by ((qualified)) health care providers who are enrolled with the medicaid agency and who meet state licensure ((and certification)) requirements, including active, unrestricted department of health (DOH) licensure. The following people may provide SBHS:

(a) Audiologists who meet the requirements ((of))described in chapters 246-828 WAC and 18.35 RCW;

(b) Licensed advanced social workers (LiACSW) who meet the requirements ((of))described in chapters 246-809 WAC and 18.225 RCW;

(c) Licensed independent clinical social workers (LiCSW) who meet the requirements described in chapters 246-809 WAC and 18.225 RCW;

(d) Licensed mental health counselors (LMHC) who meet the requirements ((of))described in chapters 246-809 WAC and 18.225 RCW;

(e) Licensed mental health counselor associates (LMHCA) who meet the requirements ((of))described in chapters 246-809 WAC and 18.225 RCW and are under the direction and supervision of a qualified LiACSW, LiCSW, or LMHC;

(f) Licensed registered nurses (RN) who meet the requirements ((of))described in chapters 246-840 WAC and 18.79 RCW;

(g) Licensed practical nurses (LPN) who meet the requirements ((of))described in chapters 246-840 WAC and 18.79 RCW and are under the direction and supervision of a ((qualified))licensed RN;

(h) ((Noncredentialed))Nonlicensed school employees who are delegated certain limited health care tasks by an RN and are supervised according to professional practice standards in RCW 18.79.260, 18.79.290, and 28A.210.275;

(i) Licensed occupational therapists (OT) who meet the requirements ((of))described in chapters 246-847 WAC and 18.59 RCW;

(j) Licensed occupational therapist assistants (OTA) who meet the requirements ((of))described in chapters 246-847 WAC and 18.59 RCW and are under the direction and supervision of a ((qualified))licensed OT;

(k) Licensed physical therapists (PT) who meet the requirements ((of))described in chapters ((246-924 WAC and 18.83))246-915 WAC and 18.74 RCW;

(l) Licensed physical therapist assistants (PTA) who meet the requirements ((of))described in chapters 246-915 WAC and 18.74 RCW and are under the direction and supervision of a licensed PT;

(m) Licensed psychologists who meet the requirements ((of))described in chapters 246-924 WAC and 18.83 RCW;

(n) Licensed speech-language pathologists (SLP) who meet the requirements ((of))described in chapters 246-828 WAC and 18.35 RCW; and

(o) Speech-language pathology assistants (SLPA) who meet the requirements ((of))described in chapters 246-828 WAC and 18.35 RCW and who are under the direction and supervision of a licensed SLP.

(2) For services provided under the supervision of a PT, OT, SLP, nurse, counselor, or social worker, the supervising provider must:

(a) Ensure the child receives quality therapy services by providing supervision in accordance with professional practice standards; and

(b) ((See the child face-to-face when services begin and at least once more during the school year;

(c))) Approve and cosign all treatment notes written by the supervisee before submitting claims for payment((; and

(d) Record supervisory activities and provide the documents to the agency or its designee upon request)).

(3) The school district must ensure providers meet the professional licensing ((and certification)) requirements described in the agency's SBHS billing guide and in this chapter.

(4) The licensing exemptions found in the following regulations do not apply to federal medicaid reimbursement:

(a) Counseling under RCW 18.225.030;

(b) Psychology under RCW 18.83.200;

(c) Social work under RCW 18.320.010; and

(d) Speech therapy under RCW 18.35.195.

All services covered under this section may be provided through telemedicine as described in WAC 182-531-1730 and in the agency's school-based health care services (SBHS) billing guide. Covered services include:

(1) Evaluations when the child is determined to have a disability, and is in need of early intervention services or special education and health care-related services that result in an individualized education program (IEP) or individualized family service plan (IFSP);

(2) Health care-related services ((including))authorized in an IEP or IFSP limited to:

(a) Audiology;

(b) Counseling;

(c) School health services and school nursing services;

(d) Occupational therapy;

(e) Physical therapy;

(f) Psychological assessments and services; and

(g) Speech-language therapy.

(3) Reevaluations, to determine whether a child continues to need early intervention services or special education and health care-related services.

Noncovered services include, but are not limited to the following:

(1) Applied behavior analysis (ABA);

(2) Attending meetings;

(3) Charting;

(4) ((Equipment preparation;

(6))) Instructional assistant contact;

(((7)))(5) Observation not provided directly after service delivery;

(((8)))(6) Parent consultation;

(((9)))(7) Parent contact;

(((10)))(8) Planning;

(((11)))(9) Preparing and sending correspondence to parents or other professionals;

(((12)))(10) Professional consultation;

(((13)))(11) Report writing;

(((14)))(12) Review of records;

(((15)))(13) School district staff accompanying a child who requires special education services to and from school on the bus when direct services are not provided;

(14) Supervision;

(((16)))(15) Teacher contact;

(((17)))(16) Test interpretation; and

(((18)))(17) Travel and transporting.

To receive payment from the medicaid agency for providing school-based health care services (SBHS) to eligible children, a school district must:

(1) Enroll as a billing provider in ProviderOne and have a current, signed core provider agreement (CPA) with the agency.

(2) Have a current, signed, and executed interagency agreement with the agency.

(3) Meet the applicable requirements in chapter 182-502 WAC.

(4) Comply with the agency's current, published ProviderOne billing and resource guide.

(5) Bill according to the agency's current ((school-based health care services provider guide, the school-based health care services))SBHS billing guide and the SBHS fee schedule((, and)).

(6) Comply with the intergovernmental transfer (IGT) process. ((After a school district receives its invoice from the agency,))The school district must provide its local match to the agency within one hundred twenty days of the invoice date.

(b) School districts may resubmit denied claims within twenty-four months from the date of service under WAC 182-502-0150.

(((6)))(7) Provide only health care-related services identified through a current individualized education program (IEP) or individualized family service plan (IFSP).

(((7)))(8) Use only licensed health care ((professionals qualified))providers under WAC 182-537-0350.

(((8)))(9) Enroll licensed health care providers as servicing providers under the school district's ((national provider identifier (NPI) number))ProviderOne account, and ensure providers have their own national provider identifier (NPI) number.

(((9)))(10) Meet documentation requirements described in WAC 182-537-0700.

(1) Providers must document all school-based health care services (((SBHS))) as required in this section((, WAC 182-502-0020,)) and the medicaid agency's school-based health care services ((provider))(SBHS) billing guide.

(2) ((All required documentation must include the provider's printed name, handwritten or electronic signature, and title. Assistants practicing under WAC 182-537-0350 must have a licensed supervisor cosign all documents as required by this subsection.

(a) Professional))Documentation to justify billed claims must be maintained for at least six years from the date of service.

(b) Assessment reports;

(((b)))(c) Evaluation and reevaluation reports;

(((c) IEP or IFSP; and))

(d) Individualized education program (IEP) or individualized family service plan (IFSP);

(f) Treatment notes. (((4))) Treatment notes must include the:

(((a)))(i) Child's name;

(((b)))(ii) Child's ProviderOne client ID;

(((c)))(iii) Child's date of birth;

(((d)))(iv) Date of service, and for each date of service:

(((i)))(A) Time-in;

(((ii)))(B) Time-out;

(((iii)))(C) A procedure code for and description of each service provided;

(((iv)))(D) The child's progress related to each service;

(((v) Number of units billed for the service; and

(vi)))(E) Whether the ((treatment))occupational therapy, speech-language therapy, physical therapy or counseling service described in the note was individual or group therapy;

(G) Assistants, as defined in WAC 182-537-0350, who provide health care-related services, must have their supervising provider cosign all treatment notes in accordance with the supervisory requirements for the provider type.

(((5)))(4) The agency accepts electronic records and signatures. Maintaining the records in an electronic format is acceptable only if the original records are available to the agency for program integrity activities for up to six years after the date of service. Each school district is responsible for determining what standards are consistent with state and federal electronic record and signature requirements.

(((6)))(5) For a signature to be valid, it must be handwritten or electronic. Signature by stamp is acceptable only if the provider is unable to sign by hand due to a physical disability.

(((7)))(6) School districts must maintain a signature log to support the provider's signature identity.

(((8)))(7) The signature log must include the provider's:

(a) Printed name;

(b) Handwritten signature;

(c) Initials;

(d) Credentials;

(e) License number; and

(f) National provider identifier (NPI) ((number)).

(((9)))(8) Each school district must establish policies and procedures to ensure complete, accurate, and authentic records. These policies and procedures must include:

(a) Security provisions to prevent the use of an electronic signature by anyone other than the licensed provider to ((which))whom the electronic signature belongs;

(b) Procedures that correspond to recognized standards and laws and protect against modifications;

(c) Protection of the privacy and integrity of the documentation;

(d) A list of which documents will be maintained and signed electronically; and

(e) Verification of the signer's identity at the time the signature was generated.

(1) To ensure compliance with program rules, the medicaid agency conducts program integrity activities under chapters 182-502 and 182-502A WAC.

(2) School districts must participate in all program integrity activities.

(3) School districts are responsible for the accuracy, compliance, and completeness of all claims submitted for medicaid ((reimbursement))payment.

(4) The agency conducts reviews and recovers overpayments if a school district does not comply with agency requirements according to agency rules.