HEALTH CARE AUTHORITY

[Filed January 27, 2022, 9:57 a.m., effective February 27, 2022]

Effective Date of Rule: Thirty-one days after filing.

Purpose: The agency is amending subsection (3)(c) of this rule, which states that the agency does not pay separately for certain services provided within one calendar day of an inpatient hospital admission. The agency is adding to this section to state that separate payments are not made for certain services provided within one calendar day of discharge.

The agency is also removing subsections (6) and (7). These subsections reference the maximum allowable fee schedule and the hospital outpatient rate for payment of certain services. The agency is making these changes because it does not use these payment methods, but instead uses the enhanced ambulatory payment group method to determine payments, consistent with WAC 182-550-7200.

Citation of Rules Affected by this Order: Amending WAC 182-550-6000.

Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.

Adopted under notice filed as WSR 22-01-045 on December 7, 2021.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.

Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.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: January 27, 2022.

AMENDATORY SECTION(Amending WSR 15-18-065, filed 8/27/15, effective 9/27/15)

WAC 182-550-6000Outpatient hospital services—Conditions of payment and payment methods.

(1) The medicaid agency pays hospitals for covered outpatient hospital services provided to eligible clients when the services meet the provisions in WAC 182-550-1700. All professional medical services must be billed according to chapter 182-531 WAC.

(2) To be paid for covered outpatient hospital services, a hospital provider must:

(a) Have a current core provider agreement with the agency;

(b) Bill the agency according to the conditions of payment under WAC 182-502-0100;

(d) Meet program requirements in other applicable WAC and the agency's published issuances.

(3) The agency does not pay separately for any services:

(a) Included in a hospital's room charges;

(b) Included as covered under the agency's definition of room and board (e.g., nursing services). See WAC 182-550-1050; or

(c) Related to an inpatient hospital admission and provided within one calendar day of a client's inpatient admission or discharge.

(4) The agency does not pay:

(a) A hospital for outpatient hospital services when a managed care plan is contracted with the agency to cover these services;

(b) More than the "acquisition cost" ("A.C.") for HCPCS (health care common procedure coding system) codes noted in the outpatient fee schedule; or

(c) For cast room, emergency room, labor room, observation room, treatment room, and other room charges in combination when billing periods for these charges overlap.

(5) The agency uses the outpatient weighted costs-to-charges (OWCC) rate to pay for covered outpatient services provided in a critical access hospital (CAH). See WAC 182-550-2598.

(6) ((The agency uses the maximum allowable fee schedule to pay non-OPPS hospitals and non-CAH hospitals for the following types of covered outpatient hospital services listed in the agency's current published outpatient hospital fee schedule and billing instructions:

(a) EKG/ECG/EEG and other diagnostics;

(b) Imaging services;

(d) Laboratory services;

(e) Occupational therapy;

(f) Physical therapy;

(g) Sleep studies;

(h) Speech/language therapy;

(i) Synagis; and

(j) Other hospital services identified and published by the agency.

(7) The agency uses the hospital outpatient rate as described in WAC 182-550-4500 to pay for covered outpatient hospital services when:

(a) A hospital provider is a non-OPPS or a non-CAH provider; and

(b) The services are not included in subsection (6) of this section.

(8))) Hospitals must provide documentation as required or requested by the agency.

(((9)))(7) All hospital providers must present final charges to the agency within ((three hundred sixty-five))365 days of the "statement covers period from date" shown on the claim. The state of Washington is not liable for payment based on billed charges received beyond ((three hundred sixty-five))365 days from the "statement covers period from date" shown on the claim.