PDFWAC 182-502-0100

General conditions of payment.

(1) The medicaid agency reimburses for medical services furnished to an eligible client when all the following apply:
(a) The service is within the scope of care of the client's Washington apple health program;
(b) The service is medically necessary;
(c) The service is properly authorized;
(d) The provider bills within the time frame set in WAC 182-502-0150;
(e) The provider bills according to agency rules and billing instructions; and
(f) The provider follows third-party payment procedures.
(2) The agency is the payer of last resort, unless the other payer is:
(a) An Indian health service;
(b) A crime victims program through the department of labor and industries; or
(c) A school district for health services provided under the Individuals with Disabilities Education Act.
(3) The agency does not reimburse providers for medical services identified by the agency as client financial obligations, and deducts from the payment the costs of those services identified as client financial obligations. Client financial obligations include, but are not limited to, the following:
(a) Copayments (copays) (unless the criteria in chapter 182-517 WAC or WAC 182-501-0200 are met);
(b) Deductibles (unless the criteria in chapter 182-517 WAC or WAC 182-501-0200 are met); and
(c) Spenddown (see WAC 182-519-0110).
(4) The provider must accept medicare assignment for claims involving clients eligible for both medicare and Washington apple health before the agency makes any payment.
(5) The provider is responsible for verifying whether a client has Washington apple health coverage for the dates of service.
(6) The agency may reimburse a provider for services provided to a person if it is later determined that the person was ineligible for the service when it was provided if:
(a) The agency considered the person eligible at the time of service;
(b) The service was not otherwise paid for; and
(c) The provider submits a request for payment to the agency.
(7) The agency does not pay on a fee-for-service basis for a service for a client who is enrolled in a managed care plan when the service is included in the plan's contract with the agency.
(8) Information about medical care for jail inmates is found in RCW 70.48.130.
(9) The agency pays for medically necessary services on the basis of usual and customary charges or the maximum allowable fee established by the agency, whichever is lower.
[Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-502-0100, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0100, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-014, § 388-502-0100, filed 5/9/11, effective 6/9/11; WSR 10-19-057, § 388-502-0100, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 71.05.560, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. WSR 06-13-042, § 388-502-0100, filed 6/15/06, effective 7/16/06. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.530. WSR 00-15-050, § 388-502-0100, filed 7/17/00, effective 8/17/00.]