(1) This section applies to the agency's authorization and utilization review (UR) of inpatient and outpatient hospital services provided to Washington apple health (WAH) clients receiving services through the fee-for-service program. For clients eligible under other WAH programs, see chapter 182-538
WAC for managed care organizations, and chapter 388-865
WAC for mental health treatment programs coordinated through the department of social and health services' division of behavioral health and recovery or its designee. See chapter 182-546
WAC for transportation services.
(2) All hospital services paid for by the agency are subject to UR for medical necessity, appropriate level of care, and program compliance.
(3) Authorization for inpatient and outpatient hospital services is valid only if a client is eligible for covered services on the date of service. Authorization does not guarantee payment.
(4) The agency will deny, recover, or adjust hospital payments if the agency or its designee determines, as a result of UR, that a hospital service does not meet the requirements in federal regulations and WAC.
(5) The agency may perform one or more types of UR described in subsection (6) of this section.
(6) The agency's UR:
(a) Is a concurrent, prospective, and/or retrospective (including postpay and prepay) formal evaluation of a client's documented medical care to assure that the services provided are proper and necessary and of good quality. The review considers the appropriateness of the place of care, level of care, and the duration, frequency or quantity of services provided in relation to the conditions(s) being treated; and
(b) Includes one or more of the following:
(i) "Concurrent utilization review"—An evaluation performed by the agency or its designee during a client's course of care. A continued stay review performed during the client's hospitalization is a form of concurrent UR;
(ii) "Prospective utilization review"—An evaluation performed by the agency or its designee prior to the provision of health care services. Preadmission authorization is a form of prospective UR; and
(iii) "Retrospective utilization review"—An evaluation performed by the agency or its designee following the provision of health care services that includes both a post-payment retrospective UR (performed after health care services are provided and paid), and a prepayment retrospective UR (performed after health care services are provided but prior to payment). Retrospective UR is routinely performed as an audit function.
(7) During the UR process, the agency or its designee notifies the appropriate oversight entity if either of the following is identified:
(a) A quality of care concern; or
(b) Fraudulent conduct.
[Statutory Authority: RCW 41.05.021
, Public Law 111-148, 42 C.F.R. § 431, 435, and 457, and 45 C.F.R. § 155. WSR 14-16-019, § 182-550-1700, filed 7/24/14, effective 8/24/14. WSR 11-14-075, recodified as § 182-550-1700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090
. WSR 07-14-018, § 388-550-1700, filed 6/22/07, effective 8/1/07; WSR 04-20-058, § 388-550-1700, filed 10/1/04, effective 11/1/04. Statutory Authority: RCW 74.08.090
. WSR 01-02-075, § 388-550-1700, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090
, [74.09.]500, [74.09.]530 and 43.20B.020
. WSR 98-01-124, § 388-550-1700, filed 12/18/97, effective 1/18/98.]