PDFWAC 182-550-7200

OPPS—Billing requirements and payment method.

This section describes hospital provider billing requirements and the payment methods the medicaid agency uses to pay for covered outpatient hospital services provided by hospitals included in the outpatient prospective payment system (OPPS).
(1) Providers must bill according to national correct coding initiative (NCCI) standards maintained by the Centers for Medicare and Medicaid Services (CMS).
ENHANCED AMBULATORY PATIENT GROUP (EAPG) METHOD
(2) The agency uses the enhanced ambulatory patient group (EAPG) method as the primary payment method for OPPS. Examples of services paid by the EAPG method include:
(a) Surgeries;
(b) Significant procedures;
(c) Observation services;
(d) Medical visits;
(e) Dental procedures; and
(f) Ancillary services.
OPPS MAXIMUM ALLOWABLE FEE SCHEDULE
(3) The agency pays using the outpatient fee schedule for:
(a) Covered services exempted from the EAPG payment method due to agency policy;
(b) Covered services for which there are no established relative weights, such as:
(i) Durable medical equipment procedures grouped to EAPG type 7; and
(ii) Physical therapy procedures grouped to EAPG type 21;
(c) Corneal tissue acquisition; and
(d) Other services as identified by the agency and posted on the agency's website.
HOSPITAL OUTPATIENT RATIO OF COSTS-TO-CHARGES (RCC)
(4) The agency uses the hospital outpatient ratio of costs-to-charges (RCC) in WAC 182-550-3900 and 182-550-4500 to pay for the services listed in subsection (3) of this section for which the agency has not established a maximum allowable fee.
[Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-14-049, § 182-550-7200, filed 6/25/14, effective 7/26/14. WSR 11-14-075, recodified as § 182-550-7200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.09.500, and 74.09.530. WSR 10-08-023, § 388-550-7200, filed 3/30/10, effective 4/30/10. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-13-100, § 388-550-7200, filed 6/20/07, effective 8/1/07; WSR 04-20-061, § 388-550-7200, filed 10/1/04, effective 11/1/04.]