PDFWAC 182-501-0160

Exception to rule—Request for a noncovered health care service.

A client or the client's provider may request that the medicaid agency or its designee 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 ETR if the requested service is excluded under state statute.
(3) Any item or service for which an ETR is requested must:
(a) Fall within accepted standards and precepts of good medical practice;
(b) Represent cost-effective 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 ETR request:
(a) The client 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.
(b) The client's health care provider must certify that medical treatment or items of service which are covered under the client's 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 written notification to the provider and the client:
(a) Approving the ETR request;
(b) Denying the 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 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 ETR request.
(6) A client does not have a right to a fair hearing on ETR decisions.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-044, § 182-501-0160, filed 8/27/15, effective 9/27/15. Statutory Authority: RCW 41.05.021. WSR 13-18-035, § 182-501-0160, filed 8/28/13, effective 9/28/13. Statutory Authority: RCW 41.05.021 and section 1927 of the Social Security Act. WSR 12-18-062, § 182-501-0160, filed 8/31/12, effective 10/1/12. WSR 11-14-075, recodified as § 182-501-0160, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-501-0160, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.04.050, 74.09.035. WSR 00-03-035, § 388-501-0160, filed 1/12/00, effective 2/12/00. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-501-0160, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-030.]