Date of Adoption: January 12, 2000.

Purpose: These rules were rewritten to comply with the principles in the Governor's Executive Order 97-02.

WAC 388-501-0165 is amended to clarify directions for requesting prior authorization for a medical or dental service or medical equipment. It is further amended to reflect MAA's current practice of offering fair hearing rights for denials of noncovered services and equipment.

WAC 388-501-0160 provides directions for requesting a noncovered service or equipment as an exception to rule, and clarifies the total time (from receipt to notification) of processing an exception to rule (timelines were in WAC 388-200-1160 (which is being repealed by this order)). This rule previously referenced WAC 388-200-1150, which was repealed and replaced with chapter 388-440 WAC. Chapter 388-440 WAC is being amended on a separate CR-103 to clarify that it does not apply to requests for noncovered medical on dental services or equipment.

WAC 388-200-1160 is being repealed.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-200-1160; and amending WAC 388-501-0160 and 388-501-0165.

Statutory Authority for Adoption: RCW 74.08.090, 74.04.050, 74.09.035.

Adopted under notice filed as WSR 99-20-107 on October 6, 1999.

Changes Other than Editing from Proposed to Adopted Version: After careful review and consideration of the comments received in response to the proposed rules, MAA made the following changes:

WAC 388-501-0165: MAA changed the wording and reorganized WAC 388-501-0165 so that it applies to all requests for prior authorization (for covered and noncovered services/equipment). It describes the notice MAA sends when denying a noncovered service, which includes notification of hearing rights. It also allows MAA to approve a noncovered service or equipment as an exception to rule (ETR), even if the client or provider did not specifically ask for an exception. This does not limit the provider/client's right to request an ETR according to the provisions of WAC 388-501-0160 if their request for a noncovered service or equipment is denied based on WAC 388-501-0165.

The adopted version clarifies that MAA makes the determination in subsection (2).

MAA replaced the reference to "community standard of practice" with "medical/dental standard of practice" and further clarified by adding the word "investigative."

MAA also clarified issues around requesting and paying for an independent medical/dental assessment.

WAC 388-501-0160 was changed in response to public comments by:

•	Clarifying that a client and/or their provider can request an exception to rule, and
•	Deleting the requirement that documentation must be submitted by the provider. The clinical information should come from the provider, but can be packaged and sent by the client or the client's representative.

The changes were made in response to public comments received by MAA. A copy of the concise explanatory statement is available by contacting Paige Wall, Department of Social and Health Services, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, phone (360) 664-6094, e-mail wallpg@dshs.wa.gov.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 2, Repealed 1.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 2, Repealed 1.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 2, Repealed 1. Effective Date of Rule: Thirty-one days after filing.

January 12, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

A client ((request for an exception to policy for medical care services denied by strict application of a rule or regulation shall require approval by medical assistance administration.      See WAC 388-200-1150 for exception to policy procedures)) and/or their provider may request prior authorization for MAA to pay for a noncovered medical or dental service, or related equipment. This is called an exception to rule.

(1) MAA cannot approve an exception to rule if the exception violates state or federal law or federal regulation.

(2) For MAA to consider the request, sufficient client-specific information and documentation must be submitted for the MAA medical director or designee to determine if:

(a) The client's clinical condition is so different from the majority that there is no equally effective, less costly covered service or equipment that meets the client's need(s); and

(b) The requested service or equipment will result in lower overall costs of care for the client.

(3) The MAA medical director or designee evaluates and considers requests on a case-by-case basis according to the information and documentation submitted from the provider.

(4) Within fifteen working days of MAA's receipt of the request, MAA notifies the provider and the client, in writing, of MAA's decision to grant or deny the exception to rule.

(5) Clients do not have a right to a fair hearing on exception to rule decisions.

[Statutory Authority: RCW 74.08.090.      94-10-065 (Order 3732), § 388-501-0160, filed 5/3/94, effective 6/3/94.      Formerly WAC 388-81-030.]

     The following section of the Washington Administrative Code is repealed:

WAC 388-200-1160

Notification of exception to rule request and decision.

2557.9
AMENDATORY SECTION(Amending Order 3732, filed 5/3/94, effective 6/3/94)

WAC 388-501-0165
((Medical services request)) Determination process for coverage of medical equipment and medical or dental services.

This section applies to fee for service (FFS) requests for medical equipment and medical or dental services that require prior authorization.

(1) ((The department shall evaluate the request for medical services as described under chapter 388-86 WAC.

(2) The department shall base a decision to approve or deny a service on obtainable evidence that establishes whether the service is "medically necessary" as defined under WAC 388-500-0005.

(a) In each case, the department shall:

(i) Make an individualized decision whether a requested service is "medically necessary"; and

(ii) Base such decision only on information contained in the client's file.

(b) The evidence must be sufficient to determine that the requested service is or is not "medically necessary," and may include:

(i) A physiological description of the disease, injury, impairment, or other ailment;

(ii) Pertinent laboratory findings;

(iii) X-ray reports;

(iv) Patient profiles; and

(v) Other objective medical information, including but not limited to medically acceptable clinical findings and diagnoses resulting from physical or mental examinations.

(3) In deciding to approve or deny a durable medical equipment or prosthetic device request, the department shall give substantial weight to objective medical information, and conclusions based thereon, from an examining physician responsible for the client's diagnosis or treatment or both when:

(a) There is an uncontradicted and adequately substantiated conclusion of an examining physician that the requested service is "medically necessary." The department shall accept the examining physician's conclusion unless the department presents specific detailed reasons for rejecting that conclusion that are consistent with sound medical practice and supported by objective medical information in the client's file.

(b) Two or more examining physicians provide conflicting medical information on conclusions about whether the requested durable medical equipment or a prosthetic device is "medically necessary," the department may conclude the durable medical equipment or a prosthetic device is not "medically necessary" only if the department enumerates specific reasons for its conclusion that are supported by objective medical information in the client's file.

(4) The department shall deny a requested service when the service is:

(a) Not medically necessary as defined under WAC 388-500-0005;

(b) Generally regarded by the medical profession as experimental in nature or as unacceptable treatment; or

(c) Unless the client demonstrates through sufficient objective clinical evidence the existence of particular circumstances rendering the requested service medically necessary; or

(d) Not a covered service.

(5) The department shall:

(a) Approve or deny all requests for medical services within fifteen days of the receipt of the request; or

(b) Return a request to the requesting provider when the information submitted is insufficient for a determination of medical necessity and the requested service is a covered service.      The department shall make a request for justifying additional information from the requesting provider within fifteen calendar days of the original receipt.      If additional information is:

(i) Not received by the department within thirty days of the date requested, the department shall deny the original request within five days after the thirty-day period on the basis of insufficient justification of medical necessity;

(ii) Received by the department, the department shall make a final determination on the request within five working days of the receipt of the additional information.

(c) Send to the client a copy of the request for additional information justifying medical necessity for durable medical equipment or a prosthetic device.

(6) When the department denies)) MAA evaluates requests on an individual basis, and bases the decision to approve or deny on submitted and obtainable evidence.

(2) MAA denies a request when MAA determines the service or equipment is not:

(a) Medically/dentally necessary;

(b) Covered; or

(c) Generally considered as acceptable treatment by the medical/dental profession based on the medical/dental standard of practice, or is investigative or experimental in nature. However, MAA may approve such a request if the provider submits sufficient objective clinical evidence demonstrating that a client's particular circumstances make the request medically/dentally necessary.

(3) Requests for covered services and equipment are approved when MAA determines that the service or equipment is medically necessary as defined in WAC 388-500-0005 or dentally necessary as defined in WAC 388-535-1050.

(4) The examining physician/dentist responsible for the client's diagnosis and/or treatment must submit specific evidence sufficient to determine if the covered service or equipment is medically/dentally necessary. Such evidence may include, but is not limited to:

(a) A client-specific physiological description of the disease, injury, impairment, or other ailment;

(b) Pertinent laboratory findings;

(c) X-ray and/or imaging reports;

(d) Individual patient records pertinent to the case or request;

(e) Photographs and/or videos when requested by MAA;

(f) Dental x-rays; and

(g) Objective medical/dental information, including but not limited to medically/dentally acceptable clinical findings and diagnoses resulting from physical or mental examinations.

(5) MAA gives substantial weight to objective medical/dental information and resulting conclusions from an examining physician/dentist responsible for the client's diagnosis and/or treatment.

(a) MAA accepts the examining physician's/dentist's uncontradicted and adequately substantiated conclusion with respect to medical/dental necessity, unless MAA presents specific detailed reasons for rejecting that conclusion. MAA's reasons will be consistent with sound medical/dental practice and supported by objective medical/dental information in the client's file.

(b) If two or more examining physicians/dentists provide conflicting medical/dental information or conclusions about medical/dental necessity for the request under review, MAA will use all information submitted to reach a decision. If MAA concludes the request is not medically/dentally necessary, MAA will enumerate specific reasons, supported by objective medical/dental information in the client's file, for that decision.

(6) Within fifteen calendar days of receiving a request:

(a) MAA approves or denies the request; or

(b) Requests additional justifying information from the prescribing physician, dentist, specialty therapist, and/or service vendor if the documentation submitted is insufficient to reasonably determine medical or dental necessity. Examples of information that MAA may request are shown in subsection (4) of this section. MAA sends a copy of the request to the client at the same time.

(i) If MAA does not receive the information within thirty days of the date requested, MAA denies the original request within the next five working days on the basis of insufficient justification of medical/dental necessity;

(ii) If MAA receives the information within thirty days, MAA makes a final determination on the request within five working days of the receipt of that additional information.

(7) When MAA denies all or part of a request ((for medical services, including all or part of a requested service, the department shall)) for a covered service(s) or equipment, MAA sends ((, within five working days of the decision, give)) the client and the provider written notice of the denial((.      The department shall ensure the notice states)) within five working days of the decision. The notice includes:

(a) The WAC reference(s) used as a basis for the decision;

(b) A summary statement of the specific facts ((the department)) MAA relied upon for the decision;

(c) An explanation of the reasons for the denial, including the reasons why the specific facts relied ((on)) upon did not meet the requirements for approval;

(d) When required ((under)) by subsection (((3))) (5) of this section, a specific statement of the reasons and supporting facts for rejecting any medical/dental information or conclusions of an examining physician/dentist;

(e) Notice of the client's right to a fair hearing ((if the request is made within ninety days of the receipt of the denial)) and filing deadlines;

(f) ((The)) Instructions ((on)) about how to request the hearing;

(g) A statement that the client may be represented at the hearing by legal counsel or other representative; and

(h) Upon the client's request, the name and address of the nearest legal services office((; and

(i) If a fair hearing is requested, a medical assessment from other than the person involved in making the original decision may be obtained at the department's expense)).

(8) When MAA receives a request for a noncovered service(s) or equipment, MAA may:

(a) Approve the request as an exception to rule according to WAC 388-501-0160; or

(b) Deny the request as a noncovered service, and send the client and the provider written notice of the denial within five working days of the decision. The notice includes:

(i) The WAC reference(s) used as a basis for the decision;

(ii) The reason for the denial;

(iii) Notice of the client's right to a fair hearing and filing deadlines;

(iv) Instructions about how to request the hearing;

(v) A statement that the client may be represented at the hearing by legal counsel or other representative; and

(vi) Upon the client's request, the name and address of the nearest legal services office.

(9) If a fair hearing is requested, MAA or the client may request an independent medical/dental assessment. MAA will pay for the independent assessment if MAA agrees that it is necessary, or a fair hearing judge determines that the assessment is necessary.

[Statutory Authority: RCW 74.08.090.      94-10-065 (Order 3732), § 388-501-0165, filed 5/3/94, effective 6/3/94.      Formerly WAC 388-81-038.]

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