WSR 00-14-069

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed July 5, 2000, 9:23 a.m. ]

Date of Adoption: July 5, 2000.

Purpose: Establish WAC 388-502-0160 Billing a client, which describes the circumstances under which a contracted provider may or may not bill a medical assistance client.

Statutory Authority for Adoption: RCW 74.08.090 and 74.09.520.

Adopted under notice filed as WSR 00-09-075 on April 18, 2000.

Changes Other than Editing from Proposed to Adopted Version:
Changed "services not included in the scope of benefits" to "covered services." This will be consistent with other MAA rules, and will not change policy.
Struck the word "directly" from subsections (1), (4), and (5).
Clarified that the client was not responsible if MAA did not pay for the service because the provider did not satisfy the conditions of payment in billing instructions or WAC.
Added that the provider also must not "demand" or "collect" payment from a client (except as provided in this rule).
Changed phrase "the client's representative" to "anyone on the client's behalf."
Changed to require a statement in the agreement described in subsection (3)(b) that the client is not obligated to pay for a service if it is later found that the service was covered by MAA at the time it was provided, even if MAA did not pay the provider for the service because the provider did not satisfy MAA's billing requirements.
Added (in (3)(c)) that the client must date the documentation, and that the provider must give a copy of it to the client.
Struck the example of CHIP in subsection (3)(f), so this subsection is consistent with the current rule.
Struck "or the client's representative" from subsection (3)(c).
Added "promptly" to subsection (4)(a)(ii).
Changed structure in subsection (4) to clarify that providers needed to return the clients payment before billing MAA.
Changed the term "MAA client" to "receiving medical assistance" for clarity in subsection (3)(d).
Added "except for spenddown" to subsection (5) as a clarification.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 1, Amended 0, Repealed 0.

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

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 0. Effective Date of Rule: Thirty-one days after filing.

July 5, 2000

Edith M. Rice, Chief

Office of the Legal Affairs

2731.4
NEW SECTION
WAC 388-502-0160
Billing a client.

(1) A provider may not bill, demand, collect, or accept payment from a client or anyone on the client's behalf for a covered service. The client is not responsible to pay for a covered service even if MAA does not pay for the service because the provider failed to satisfy the conditions of payment in MAA billing instructions, this chapter, and other chapters regulating the specific type of service provided.

(2) The provider is responsible to verify whether the client has medical coverage for the date of service and to check the limitations of the client's medical program.

(3) A provider may bill a client only if one of the following situations apply:

(a) The client is enrolled in a managed care plan and the client and provider comply with the requirements in WAC 388-538-095;

(b) The client is enrolled in a program other than managed care, and the client and provider sign an agreement. It must be translated or interpreted into the client's primary language and signed before the service is rendered. The provider must give the client a copy and maintain the original in the client's file for department review upon request. The agreement must include each of the following elements to be valid:

(i) The specific service to be provided;

(ii) The service is not covered;

(iii) The client chooses to receive and pay for the specific service; and

(iv) The client is not obligated to pay for the service if it is later found that the service was covered by MAA at the time it was provided, even if MAA did not pay the provider for the service because the provider did not satisfy MAA's billing requirements;

(c) The client or the client's legal guardian was reimbursed for the service directly by a third party;

(d) The provider has documentation that the client represented himself/herself as a private pay patient and not receiving medical assistance. The documentation must be signed and dated by the client or the client's representative. The provider must give a copy to the client and maintain the original documentation in the patient's file for department review upon request. If the patient later becomes eligible for the service due to delayed or retroactive eligibility, the provider must comply with subsection (4) of this section;

(e) The client refuses to complete and sign insurance forms, billing documents, or other forms necessary for the provider to bill insurance for the service. Medical Assistance is not insurance; or

(f) The bill counts toward a spenddown liability, emergency medical expense requirement, deductible, or copayment required by MAA.

(4) If a client becomes eligible for a service that has already been provided due to:

(a) Delayed eligibility, the provider must:

(i) Not bill, demand, collect, or accept payment from the client or anyone on the client's behalf for the service; and

(ii) Promptly refund the total payment received from the client or anyone on the client's behalf, and then bill MAA for the service.

(b) Retroactive eligibility, the provider:

(i) Must not bill, demand, collect, or accept payment from the client or anyone on the client's behalf for any unpaid charges for the service; and

(ii) May refund any payment received from the client or anyone on the client's behalf, and then bill MAA for the service.

(5) Hospitals may not bill, demand, collect, or accept payment from a medically indigent, GA-U, or ADATSA client, or anyone on the client's behalf, for inpatient or outpatient hospital services during a period of eligibility, except for spenddown.

(6) A provider may not bill, demand, collect, or accept payment from a client, anyone on the client's behalf, or MAA for copying or otherwise transferring health care information, as that term is defined in chapter 70.02 RCW, to another health care provider. This includes, but is not limited to:

(a) Medical charts;

(b) Radiological or imaging films; and

(c) Laboratory or other diagnostic test results.

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Washington State Code Reviser's Office