Original Notice.

Preproposal statement of inquiry was filed as WSR 99-20-048 and 00-06-022.

Title of Rule: Repealing WAC 388-502-0205 Civil rights. Also general requirements for people who are contracted with the department to provide, and be reimbursed for, services or equipment to medical assistance clients, as stated in sections of chapter 388-87 WAC.

Purpose: To eliminate duplicative rules; the language in WAC 388-502-0205 Civil rights, repeats federal antidiscrimination rules, and so is unnecessary. The policy that providers will still be required to follow department rules that ensure all participating providers will not discriminate against any client is being incorporated into WAC 388-502-0020.

To update and rewrite rules for people who provide services and/or equipment to medical assistance clients. To comply with the Governor's Executive Order 97-02.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.500, 74.09.530.

Statute Being Implemented: RCW 74.08.090, 74.09.500.

Summary: The civil rights language in WAC 388-502-0205 is already incorporated into federal antidiscrimination rules, which makes it unnecessary to be repeated in rule. The policy that providers will still be required to follow department rules that ensure all participating providers will not discriminate against any client is being incorporated into WAC 388-502-0020.

Several sections currently in chapter 388-87 WAC are being repealed and proposed as new rules in chapter 388-502 WAC.

Reasons Supporting Proposal: To comply with the Governor's Executive Order 97-02 (to update rule content to reflect current policy and practice, and to eliminate duplicative rules).

Name of Agency Personnel Responsible for Drafting: Leslie Saeger, P.O. Box 45533, Olympia, WA 98504, (360) 725-1347; Implementation and Enforcement: Ann Lawrence, P.O. Box 45533, Olympia, WA 98504, (360) 725-1347.

Name of Proponent: Department of Social and Health Services, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: The proposed rules will not change the way MAA currently does business. These rules clarify some requirements which were previously spelled out only in the provider's contract and/or billing instructions. They also eliminate repetition of federal antidiscrimination rules in state rules.

Proposal Changes the Following Existing Rules: The following rules are being repealed: WAC 388-87-005 Payment -- Eligible providers defined, 388-87-007 Medical provider agreement, 388-87-008 Disclosure by providers -- Information on ownership and control, 388-87-010 Conditions of payment -- General, 388-87-011 Conditions of payment -- Medicare deductible and coinsurance -- When paid by department, 388-87-012 Conditions of payment -- Consultant's and specialist's services and fees, 388-87-200 Payment for jail inmates medical care, and 388-502-0205 Civil rights.

No small business economic impact statement has been prepared under chapter 19.85 RCW. These rules do not change existing policy or add financial burdens to businesses.

RCW 34.05.328 does not apply to this rule adoption. The proposed rules do not make "significant amendments to a policy or regulatory program" since no policy changes have been made. Therefore, the department concludes that the proposed rules do not meet the definition of significant legislative rules.

Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on May 23, 2000, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Paige Wall by May 12, 2000, phone (360) 664-6094, TDD (360) 664-6178, e-mail wallpg@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, Paige Wall, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by May 23, 2000.

Date of Intended Adoption: May 24, 2000.

April 10, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

The department reimburses enrolled providers for covered medical services, equipment and supplies they provide to eligible clients.

(1) To be eligible for enrollment, a provider must:

(a) Be licensed, certified, accredited, or registered according to Washington state laws and rules; and

(b) Meet the conditions in this chapter and chapters regulating the specific type of provider, program, and/or service.

(2) To enroll, an eligible provider must sign a core provider agreement or a contract with the department and receive a unique provider number.

(3) Eligible providers listed in this subsection may request enrollment. Out-of-state providers listed in this subsection are subject to conditions in WAC 388-502-0120.

(a) Professionals:

(i) Advanced registered nurse practitioners;

(ii) Anesthesiologists;

(iii) Audiologists;

(iv) Chiropractors;

(v) Dentists;

(vi) Dental hygienists;

(vii) Denturists;

(viii) Dietitians or nutritionists;

(xiv) Maternity case managers;

(x) Midwives;

(xi) Occupational therapists;

(xii) Ophthalmologists;

(xiii) Opticians;

(xiv) Optometrists;

(xv) Orthodontists;

(xvi) Osteopaths;

(xvii) Podiatrists;

(xviii) Physicians;

(xix) Physical therapists;

(xx) Psychiatrists;

(xxi) Psychologists;

(xxii) Registered nurse delegators;

(xxiii) Registered nurse first assistants;

(xxiv)Respiratory therapists;

(xxv) Speech/language pathologists;

(xxvi) Radiologists; and

(xvii) Radiology technicians (technical only);

(b) Agencies, centers and facilities:

(i) Adult day health centers;

(ii) Ambulatory surgery centers (medicare-certified);

(iii) Birthing centers (licensed by the department of health);

(iv) Blood banks;

(v) Chemical dependency treatment facilities certified by the division of alcohol and substance abuse, and contracted through either:

(A) A county under chapter 388-810 WAC; or

(B) The division of alcohol and substance abuse to provide chemical dependency treatment services;

(vi) Centers for the detoxification of acute alcohol or other drug intoxication conditions (certified by the division of alcohol and substance abuse);

(vii) Community AIDS services alternative agencies;

(viii) Community mental health centers;

(ix) Early and periodic screening, diagnosis, and treatment (EPSDT) clinics;

(x) Family planning clinics;

(xi) Federally qualified health care centers (designated by HCFA);

(xii) Genetic counseling agencies;

(xiii) Health departments;

(xiv) HIV/AIDS case management;

(xv) Home health agencies;

(xvi) Hospice agencies;

(xvii) Hospitals;

(xviii) Indian Health Service;

(xix) Tribal or urban Indian clinics;

(xx) Inpatient psychiatric facilities;

(xxi) Intermediate care facilities for the mentally retarded (ICF-MR);

(xxii) Kidney centers;

(xxiii) Laboratories (CLIA certified);

(xxiv) Maternity support services agencies;

(xxv) Neuromuscular centers;

(xxvi) Nursing facilities (approved by DSHS Aging and Adult Services);

(xxvii) Pharmacies;

(xxviii) Private duty nursing agencies;

(xxix) Rural health clinics (medicare-certified);

(xxx) Tribal mental health services (contracted through the mental health division); and

(xxxi) Washington state school districts and educational service districts.

(c) Suppliers of:

(i) Durable medical equipment;

(ii) Infusion therapy equipment and supplies;

(iii) Prosthetics/orthotics;

(iv) Hearing aids; and

(v) Oxygen equipment and supplies;

(d) Contractors of:

(i) Transportation brokers;

(ii) Interpreter services agencies; and

(iii) Eyeglass and contact lens providers.

(4) The department does not pay for services performed by any licensed or unlicensed practitioners who are not specifically addressed in this chapter, including:

(a) Acupuncturists;

(b) Counselors;

(c) Sanipractors;

(d) Naturopaths;

(e) Homeopaths;

(f) Herbalists;

(g) Massage therapists; or

(h) Christian Science practitioners or theological healers.

[]

Enrolled providers must:

(1) Keep legible, accurate, and complete charts and records to justify the services provided to each client, including, but not limited to:

(i) Patient's name and date of birth;

(ii) Dates of services;

(iii) Name and title of person performing the service, if other than the billing practitioner;

(iv) Chief complaint or reason for each visit;

(v) Pertinent medical history;

(vi) Pertinent findings on examination;

(vii) Medications, equipment, and/or supplies prescribed or provided;

(viii) Description of treatment (when applicable);

(ix) Recommendations for additional treatments, procedures, or consultations;

(x) X-rays, tests, and results;

(xi) Plan of treatment and/or care, and outcome; and

(xii) Specific claims and payments received for services.

(b) Assure charts are authenticated by the person who gave the order, provided the care, or performed the observation, examination, assessment, treatment or other service to which the entry pertains;

(c) Make charts and records available to DSHS, its contractors, and the US Department of Health and Human Services upon request, for at least six years from the date of service;

(d) Bill the department according to MAA rules and billing instructions;

(e) Accept the payment specified in MAA fee schedules as payment in full;

(f) Follow the requirements in WAC 388-502-0160 and 388-538-095 about billing clients;

(g) Fully disclose ownership and control information requested by the department;

(h) Not pay a third party biller a percentage of amounts collected, or discount client accounts to a third party biller;

(i) Provide all services without discriminating on the grounds of race, creed, color, age, sex, religion, national origin, marital status, or the presence of any sensory, mental or physical handicap;

(j) Provide all services according to federal and state laws and rules, and billing instructions issued by the department; and

(k) Follow the published rules that govern MAA's programs.

(2) A provider may contact MAA with questions regarding its programs. However, MAA's response is based solely on the information provided to MAA's representative at the time of inquiry, and in no way exempts a provider from following the laws and rules that govern MAA's programs.

[]

Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
NEW SECTION
WAC 388-502-0030
Denying and suspending a provider's enrollment.

(1) MAA restricts, or does not enroll or reinstate a provider if, in MAA's judgement, it may be a danger to the health or safety of clients.

(2) Except as noted in subsection (3) of this section, MAA restricts, or does not enroll or reinstate a provider to whom any of the following apply:

(a) Has a restricted professional license;

(b) Has been terminated, excluded, or suspended from Medicare/Medicaid; or

(c) Has been terminated by the department for quality of care issues or inappropriate billing practices.

(3) MAA may choose not to deny or suspend the enrollment of a provider who meets the conditions in subsection (2) of this section if all of the following apply:

(a) The department determines the provider is not likely to repeat the violation that led to the restriction or sanction;

(b) The provider has not been convicted of other offenses related to the delivery of professional or other medical services in addition to those considered in the previous sanction; and

(c) If the United States Department of Health and Human Services (DHHS) or Medicare suspended the provider from Medicare, DHHS or Medicare notifies the department that the provider may be reinstated.

(4) The department gives thirty days written notice before suspending a provider's enrollment. However, the department suspends enrollment immediately if any one of the following situations apply:

(a) The provider is convicted of a criminal offense related to participation in the Medicare/Medicaid program;

(b) The provider's license is suspended or revoked by the Washington state department of health;

(c) Federal funding is revoked;

(d) By investigation, the department documents a violation of law or contract;

(e) The MAA medical director or designee determines the quality of care provided endangers the health and safety of one or more clients; or

(f) The department determines the provider has intentionally used inappropriate billing practices.

(5) The department may terminate a provider's number if:

(a) The provider does not submit a claim to the department for twenty-four consecutive months;

(b) The provider's address on file with the department is incorrect;

(c) The provider requests a new provider number (e.g., change in tax identification number or ownership); or

(d) The provider voluntarily withdraws from participation in the medical assistance program.

[]

(1) The department reimburses for medical services furnished to a client when all of the following apply:

(a) The service is within the scope of care of the client's medical assistance program;

(b) The service is medically or dentally necessary;

(c) The service is properly authorized;

(d) The provider bills within the timeframe set in WAC 388-502-0150;

(e) The provider bills according to MAA's rules and billing instructions; and

(f) The provider follows third-party payment procedures.

(2) The department is the payer of last resort, unless the other payer is:

(a) An Indian health service;

(b) A crime victims program through the department of labor and industries; or

(c) A school district for health services provided under the Individuals with Disabilities Education Act.

(3) The provider must accept Medicare assignment for claims involving clients eligible for both Medicare and Medicaid before Medicaid makes any payment.

(4) The provider is responsible for verifying whether a client has medical assistance coverage for the dates of service.

(5) The department does not pay on a fee-for-service basis for a service for a client who is enrolled in a managed care plan when the service is included in the plan's contract with the department.

(6) Information about medical care for jail inmates is found in RCW 70.48.130.

(7) The department pays for medically necessary services on the basis of usual and customary charges or the maximum allowable fee established by the department, whichever is lower.

[]

(1) The department pays the deductible and coinsurance amounts for a client participating in Parts A and/or B of Medicare (Title XVIII of the Social Security Act) when the:

(a) Total reimbursement to the provider from Medicare and the department does not exceed the rate in the department's fee schedule; and

(b) Provider accepts assignment for Medicare payment.

(2) The department pays the deductible and coinsurance amounts for a client who has Part A of Medicare. If the client:

(a) Has not exhausted lifetime reserve days, the department considers the Medicare diagnostic related group (DRG) as payment in full; or

(b) Has exhausted lifetime reserve days during an inpatient hospital stay, the department considers the Medicare DRG as payment in full until the Medicaid outlier threshold is reached. After the Medicaid outlier threshold is reached, the department pays an amount based on the policy described in the Title XIX state plan.

(3) The provider must accept Medicare's payment plus the department's payment for the coinsurance and deductible for medicare as payment in full.

(4) The department bases its outlier policy on the methodology described in the department's Title XIX state plan, methods, and standards used for establishing payment rates for hospital inpatient services.

(5) The department may pay for Medicaid covered services when the client exhausts Medicare benefits.

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     The following sections of the Washington Administrative Code are repealed:

WAC 388-87-005	Payment -- Eligible providers defined.
WAC 388-87-007	Medical provider agreement.
WAC 388-87-008	Disclosure by providers -- Information on ownership and control.
WAC 388-87-010	Conditions of payment -- General.
WAC 388-87-011	Conditions of payment -- Medicare deductible and coinsurance -- When paid by department.
WAC 388-87-012	Conditions of payment -- Consultant's and specialist's services and fees.
WAC 388-87-200	Payment for jail inmates medical care.

2733.1
REPEALER

     The following section of the Washington Administrative Code is repealed:

WAC 388-502-0205

Civil rights.

© Washington State Code Reviser's Office