WSR 02-16-079

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed August 6, 2002, 12:50 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 02-10-139.

Title of Rule: New WAC 388-543-1225 Provider requirements.

Purpose: The department is establishing a new section in chapter 388-543 WAC to establish specific requirements for providers who furnish items under the department's durable medical equipment program. The new section includes cross-references to general documentation and record retention requirements in chapter 388-502 WAC; requires that providers be able to furnish proof of delivery of an item to a client when that item is mailed directly or shipped; requires that providers obtain prior authorization from MAA before shipping an item that requires such; and ensures there is no conflict of interest by requiring that the medical professional who provides medical justification to MAA or who performs a client evaluation not be employed by or have any financial arrangement with the provider of the item(s). The rules are necessary to ensure providers maintain adequate documentation of items provided to clients; this will assist the department's utilization reviews, which contributes to the maintenance of fiscal responsibility.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.530.

Statute Being Implemented: RCW 74.08.090, 74.09.530, 74.09.290.

Summary: See Purpose above.

Reasons Supporting Proposal: See Purpose above.

Name of Agency Personnel Responsible for Drafting: Ann Myers, Rules and Publications, P.O. Box 45533, Olympia, WA 98504, (360) 725-1345; Implementation and Enforcement: Sharon Morrison, Quality Utilization, P.O. Box 45506, Olympia, WA 98504, (360) 725-1671.

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

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

Explanation of Rule, its Purpose, and Anticipated Effects: The department is establishing a new section in chapter 388-543 WAC to establish specific requirements for providers who furnish items under the department's durable medical equipment program. The new section includes cross-references to general documentation and record retention requirements in chapter 388-502 WAC; requires that providers be able to furnish proof of delivery of an item to a client when that item is mailed directly or shipped; requires that providers obtain prior authorization from MAA before shipping an item that requires such; and ensures there is no conflict of interest by requiring that the medical professional who provides medical justification to MAA or who performs a client evaluation not be employed by or have any financial arrangement with the provider of the item(s).

The rules are necessary to ensure providers maintain adequate documentation of items provided to clients; this will assist in the department's utilization reviews, which contribute to the maintenance of fiscal responsibility.

Proposal does not change existing rules.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the rule and concludes that it will have no more than a minor impact on the small businesses affected by it.

RCW 34.05.328 applies to this rule adoption. The department has analyzed the proposed rule and concludes that it meets the definition of a "significant legislative rule." An analysis of the probable costs and probable benefits is available from the person listed above.

Hearing Location: Blake Office Park (behind Goodyear Courtesy Tire), 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on September 10, 2002, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Andy Fernando, DSHS Rules Coordinator, by September 6, 2002, phone (360) 664-6094, TTY (360) 664-6178, e-mail FernaAX@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, DSHS Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, e-mail fernaax@dshs.wa.gov by 5:00 p.m., September 10, 2002.

Date of Intended Adoption: Not before September 11, 2002.

August 2, 2002

Bonnie Jacques

for Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

3149.3
NEW SECTION
WAC 388-543-1225   Provider requirements.   (1) Providers and suppliers of durable medical equipment (DME) and related supplies, prosthetics and orthotics, medical supplies and related items must meet the general provider documentation and record retention requirements in WAC 388-502-0020. In addition to these requirements, the medical assistance administration (MAA) requires providers to furnish, upon request, documentation of proof of delivery as stated in subsections (2) and (3) of this section.

(2) When a provider delivers an item directly to the client or the client's authorized representative, all of the following apply:

(a) A delivery slip is required and must:

(i) Be signed and dated by the client or the client's authorized representative (the date of signature must be the date the item was received); and

(ii) Include the client's name and a detailed description of the item(s) delivered, including the quantity, brand name, and serial number.

(b) When the provider or supplier submits a claim for payment to MAA, the date of service on the claim must be one of the following:

(i) For a one-time delivery, the date the item was received by the client or authorized representative; or

(ii) For nondurable medical supplies for which MAA has established a monthly maximum, on or after the date the item was received by the client or authorized representative.

(3) When a provider uses a delivery/shipping service to deliver items which are not fitted to the client, the provider must be able to furnish proof of delivery that the client received the equipment (e.g., a shipping invoice signed by the client or the client's representative).

(4) A provider must not use a delivery/shipping service to deliver items which must be fitted to the client.

(5) Providers must obtain prior authorization on any item that requires such before delivering that item to the client. The item must be delivered to the client before the provider bills MAA.

(6) MAA does not pay for DME and related supplies, prosthetics and orthotics, medical supplies and related items furnished to MAA clients when:

(a) The medical professional who provides medical justification to MAA for the item provided to the client is an employee of, has a contract with, or has any financial relationship with the provider of the item; or

(b) The medical professional who performs a client evaluation is an employee of, has a contract with, or has any financial relationship with a provider of DME and related supplies, prosthetics and orthotics, medical supplies, and related items.

(7) See WAC 388-502-0100, 388-502-0110, 388-502-0120, and 388-502-0130 for provider payment requirements.

(8) See WAC 388-502-0150 and 388-502-0160 for provider billing requirements.

(9) See WAC 388-502-0220, 388-502-0230, 388-502-0240, and 388-502-0260 for provider appeal requirements.

[]

Washington State Code Reviser's Office