(1) The respiratory care, equipment, and supplies described in this chapter applies to:
(a) Medicaid clients who require respiratory care in their homes, community residential settings, and skilled nursing facilities;
(b) Providers who supply respiratory care to medicaid clients; and
(c) Licensed health care professionals whose scope of practice allows for the provision of respiratory care.
(2) The agency covers the respiratory care listed in this chapter according to the limitations and requirements in this chapter.
(3) The agency pays for respiratory care for medicaid clients when it is:
(a) Covered;
(b) Within the scope of the eligible client's medical care program;
(c) Medically necessary, as defined under chapter
182-500 WAC;
(d) Prescribed by a physician, advanced registered nurse practitioner (ARNP), or physician assistant certified (PAC) within the scope of his or her licensure;
(e) Authorized, as required within this chapter, chapters
182-501 and
182-502 WAC, and the agency's published medicaid billing guides and provider alerts;
(f) Billed according to this chapter, chapters
182-501 and
182-502 WAC, and the agency's published medicaid billing guides and provider alerts; and
(g) Provided and used within accepted medical or respiratory care community standards of practice.
(4) The agency does not require prior authorization for requests for covered respiratory care for medicaid clients that meets the clinical criteria set forth in this chapter.
(5) The agency requires prior authorization for covered respiratory care for medicaid clients when the clinical criteria set forth in this chapter are not met, including the criteria associated with the expedited prior authorization process.
(a) The agency evaluates requests requiring prior authorization on a case-by-case basis to determine whether they are medically necessary, according to the process found in WAC
182-501-0165.
(6) The agency evaluates on a case-by-case basis for medical necessity and appropriateness items, procedures, and services that do not have an established procedure code available and which are billed using miscellaneous procedure codes.
[Statutory Authority: RCW
41.05.021,
41.05.160 and 42 C.F.R. 431.16 Section 1903 (i)(27) of the Social Security Act. WSR 19-21-087, § 182-552-0001, filed 10/14/19, effective 11/14/19. Statutory Authority: RCW
41.05.021. WSR 12-14-022, § 182-552-0001, filed 6/25/12, effective 8/1/12.]