WSR 00-14-067

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed July 5, 2000, 9:19 a.m. ]

Date of Adoption: July 5, 2000.

Purpose: The department incorporated the policy in WAC 388-87-015 Billing limitations, into new WAC 388-502-0150 Time limits for providers to bill MAA, in order to consolidate all provider-related rules in one area of Title 388 WAC. The rule is written to comply with the Governor's Executive Order 97-02 on regulatory reform and ensures that all long-standing operational policy is reflected in the rule.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-87-015.

Statutory Authority for Adoption: RCW 74.08.090 and 42 C.F.R. 447.45.

Adopted under notice filed as WSR 00-09-042 on April 14, 2000.

Changes Other than Editing from Proposed to Adopted Version: Changes that have been incorporated were the result of oral comments received after the filing of the CR-102 and the result of written testimony received in connection with the public hearing. The concise explanatory statement contains all of the detail.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 1, Amended 0, Repealed 1.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 1, Amended 0, Repealed 1.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 1, Amended 0, Repealed 1.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

July 5, 2000

Edith M. Rice, Chief

Office of Legal Affairs

2666.8
NEW SECTION
WAC 388-502-0150
Time limits for providers to bill MAA.

Providers may bill the medical assistance administration (MAA) for covered services provided to eligible clients.

(1) MAA requires providers to submit initial claims and adjust prior claims in a timely manner. MAA has three timeliness standards:

(a) For initial claims, see subsections (3), (4), (5), and (6) of this section;

(b) For resubmitted claims other than prescription drug claims, see subsections (7) and (8) of this section; and

(c) For resubmitted prescription drug claims, see subsections (9) and (10) of this section.

(2) The provider must submit claims to MAA as described in MAA's billing instructions.

(3) Providers must submit their claim to MAA and have an internal control number (ICN) assigned by MAA within three hundred sixty-five days from any of the following:

(a) The date the provider furnishes the service to the eligible client;

(b) The date a final fair hearing decision is entered that impacts the particular claim;

(c) The date a court orders MAA to cover the service; or

(d) The date the department certifies a client eligible under delayed certification criteria.

(4) MAA may grant exceptions to the three hundred sixty-five-day time limit for initial claims when billing delays are caused by either of the following:

(a) The department's certification of a client for a retroactive period; or

(b) The provider proves to MAA's satisfaction that there are other extenuating circumstances.

(5) MAA requires providers to bill known third parties for services. See WAC 388-501-0200 for exceptions. Providers must meet the timely billing standards of the liable third parties in addition to MAA's billing limits.

(6) When a client is covered by both Medicare and MAA, the provider must bill Medicare for the service before billing Medicaid. If Medicare:

(a) Pays the claim the provider must bill MAA within six months of the date Medicare processes the claim; or

(b) Denies payment of the claim, MAA requires the provider to meet the three hundred sixty-five-day requirement for timely initial claims as described in subsection (3) of this section.

(7) MAA allows providers to resubmit, modify, or adjust any claim, other than a prescription drug claim, with a timely ICN within thirty-six months of the date the service was provided to the client. This applies to any claim, other than a prescription drug claim, that met the time limits for an initial claim, whether paid or denied. MAA does not accept any claim for resubmission, modification, or adjustment after the thirty-six-month period ends.

(8) The thirty-six-month period described in subsection (7) of this section does not apply to overpayments that a provider must refund to the department. After thirty-six months, MAA does not allow a provider to refund overpayments by claim adjustment; a provider must refund overpayments by a negotiable financial instrument, such as a bank check.

(9) MAA allows providers to resubmit, modify, or adjust any prescription drug claim with a timely ICN within fifteen months of the date the service was provided to the client. After fifteen months, MAA does not accept any prescription drug claim for resubmission, modification or adjustment.

(10) The fifteen-month period described in subsection (9) of this section does not apply to overpayments that a prescription drug provider must refund to the department. After fifteen months a provider must refund overpayments by a negotiable financial instrument, such as a bank check.

(11) MAA does not allow a provider or any provider's agent to bill a client or a client's estate when the provider fails to meet the requirements of this section, resulting in the claim not being paid by MAA.

[]


REPEALER

     The following section of the Washington Administrative Code is repealed:
WAC 388-87-015 Billing limitations.

Washington State Code Reviser's Office