(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
(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
(c) Bill the agency according to the time limits under WAC 182-502-0150
(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
(c) Related to an inpatient hospital admission and provided within one calendar day of a client's inpatient admission.
(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) All hospital providers must present final charges to the agency within three hundred sixty-five 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 days from the "statement covers period from date" shown on the claim.
[Statutory Authority: RCW 41.05.021
. WSR 15-18-065, § 182-550-6000, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-6000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090
. WSR 07-13-100, § 388-550-6000, filed 6/20/07, effective 8/1/07; WSR 04-20-060, § 388-550-6000, filed 10/1/04, effective 11/1/04. Statutory Authority: RCW 74.04.050
, and Public Law 104-191. WSR 03-19-044, § 388-550-6000, filed 9/10/03, effective 10/11/03. Statutory Authority: RCW 74.08.090
(1), and 43.88.290
. WSR 02-21-019, § 388-550-6000, filed 10/8/02, effective 11/8/02. Statutory Authority: RCW 74.09.090
, 42 U.S.C. 1395x(v), 42 C.F.R. 447.271 and 42 C.F.R. 11303. WSR 99-14-028, § 388-550-6000, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090
, 42 U.S.C. 1395 x(v), 42 C.F.R. 447.271, 447.11303, and 447.2652. WSR 99-06-046, § 388-550-6000, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090
, [74.09.]500, [74.09.]530 and 43.20B.020
. WSR 98-01-124, § 388-550-6000, filed 12/18/97, effective 1/18/98.]