PDFWAC 182-543-4300

Wheelchairs—Modifications, accessories, and repairs.

(1) The medicaid agency pays for, with prior authorization, wheelchair accessories and modifications that are specifically identified by the manufacturer as separate line item charges. To receive payment, providers must submit the following to the agency:
(a) A completed General Information for Authorization form (HCA 13-835). The agency's electronic forms are available online (see WAC 182-543-7000, Authorization);
(b) A completed Prescription Form (HCA 13-794);
(c) A completed Medical Necessity for Wheelchair Purchase (for home clients only) form (HCA 13-727). The date on this form (HCA 13-727) must not be dated prior to the date on the Prescription Form (HCA 13-794);
(d) The make, model, and serial number of the wheelchair to be modified;
(e) The modification requested; and
(f) Any specific information regarding the client's medical condition that necessitates the modification.
(2) The agency pays for transit option restraints only when used for client-owned vehicles.
(3) The agency pays for, with prior authorization, wheelchair repairs. To receive payment, providers must submit the following to the agency:
(a) General Information for Authorization form (HCA 13-835). The agency's electronic forms are available online (see WAC 182-543-7000);
(b) A completed Medical Necessity for Wheelchair Purchase form (for home clients only) (HCA 13-727);
(c) The make, model, and serial number of the wheelchair to be repaired; and
(d) The repair requested.
(4) Prior authorization is required for the repair and modification of client-owned equipment.
[Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. Part 440.70; 42 U.S.C. section 1396 (b)(i)(27). WSR 18-24-021, § 182-543-4300, filed 11/27/18, effective 1/1/19. Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-4300, filed 3/25/14, effective 4/25/14. WSR 11-14-075, recodified as § 182-543-4300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-4300, filed 6/29/11, effective 8/1/11.]