(1) General.

(a) Providers must obtain authorization for all covered orally administered or tube-delivered enteral nutrition products, equipment and related supplies as required in this chapter, the agency's published billing instructions, and when the clinical criteria in this chapter are not met.

(b) Authorization does not guarantee payment.

(d) The agency may reject an incomplete authorization request and return it to the provider for further action. A returned request is not a denial of service.

(e) If a request for authorization exceeds limitations in this chapter, the agency evaluates the request under WAC 182-501-0169.

(f) If the agency determines that a service was wrongfully authorized or did not meet the expedited prior authorization (EPA) criteria, the agency may recoup payment from the provider under chapters 182-502 and 182-502A WAC.

(g) Upon request, a provider must furnish documentation to the agency that shows how the client's condition met the criteria for prior authorization (PA) or EPA.

(2) Prior authorization. PA is required for:

(a) Orally administered enteral nutrition products under WAC 182-554-500; and

(b) Tube-delivered enteral equipment, replacement parts and related supplies under WAC 182-554-600(3).

(3) Prior authorization request form. The provider must submit a request for PA on the Oral Enteral Nutrition Worksheet Prior Authorization Request form. This form is available online at http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx. This form must be:

(a) Complete, with all fields full;

(b) Completed by the prescribing physician, advanced registered nurse practitioner, or physician assistant;

(c) Written, dated, and signed (including the prescriber's credentials) by the prescriber on the same day, and before the date of delivery. This form must not be backdated; and

(d) Submitted within three months of the date the prescriber signed the prescription.

(4) Expedited prior authorization. For EPA, a provider must establish that the client's condition meets the clinically appropriate EPA criteria outlined in this chapter and in the agency's published billing instructions. The provider must use the appropriate EPA number when billing the agency.

(5) If a fee-for-service client enrolls with an agency-contracted managed care organization (MCO) before the purchase or rental of authorized equipment is complete:

(a) The agency stops paying for the equipment on the last day of the month before the month in which the client enrolls in the managed care plan; and

(b) The MCO may reevaluate the client's need for the equipment.

(6) The agency may rescind authorization for enteral equipment if the client:

(a) Enrolls in, or becomes eligible for, an MCO;

(b) Becomes covered by a hospice agency and the equipment is used in the treatment of the terminal diagnosis or related condition(s);

(d) Dies.

PDFWAC 182-554-700

Enteral nutrition products, equipment and related supplies—Authorization.