WSR 11-11-017



(Medicaid Purchasing Administration)

[ Filed May 9, 2011, 8:53 a.m. , effective June 9, 2011 ]

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

Purpose: The department of social and health services' medicaid purchasing administration (MPA) is proposing to amend WAC 388-502-0010 Payment -- Eligible providers defined, 388-502-0020 General requirements for providers, 388-502-0030 Denying, suspending, and terminating a provider's enrollment, and 388-502-0230 Provider review and appeal.

These rule amendments and additions are intended to update, clarify, and ensure rules which protect the health and safety of DSHS clients and further ensure program integrity. This includes, but is not limited to, eligible provider types, noneligible provider types, core provider agreement, enrollment, review and consideration of an applicant's history, continuing requirements, change of ownership, healthcare record requirements, termination of a provider for cause or convenience, provider dispute of a department decision, reapplying for participation, and provider review and appeal.

Citation of Existing Rules Affected by this Order: Amending WAC 388-502-0010, 388-502-0020, 388-502-0030, and 388-502-0230.

Statutory Authority for Adoption: RCW 74.08.090.

Other Authority: RCW 74.09.080 and 74.09.290.

Adopted under notice filed as WSR 11-05-078 on February 15, 2011.

Changes Other than Editing from Proposed to Adopted Version: WAC 388-502-0005 Core provider agreement (CPA).

The department revised subsections (4) and (5) of this section in response to stakeholder comments.

(1) All healthcare professionals, healthcare entities, suppliers or contractors of service must have an approved core provider agreement (CPA) or be enrolled as a performing provider on an approved CPA to provide healthcare services to an eligible medical assistance client; otherwise any request for payment will be denied.

(2) For services provided out-of-state refer to WAC 388-501-0180, 388-501-0182 and 388-501-0184.

(3) All performing providers of services to a medical assistance client must be enrolled under the billing provider's CPA.

(4) The department does not pay for services provided to clients during the CPA application process, regardless of whether the CPA is later approved or denied, except as provided in subsection (5) of this section.

(5) Enrollment of a provider applicant is effective no earlier than the date of approval of the provider application.

(a) For federally qualified health centers (FQHCs), see WAC 388 548 1200. For rural health clinics (RHCs), see WAC 388 549 1200.

(b) Any other exceptions must be requested in writing to the department medicaid director by providing with justification as to why the applicant's effective date should be back dated prior to the CPA approval date. Exceptions will only be considered for emergency services, department approved out-of-state services or if the client was given retroactive eligibility. The requested effective date must be noted and must be covered by any applicable license or certification submitted with this application. This also applies to healthcare practitioners who join an established group or clinic as a performing provider, when the established group or clinic has an existing CPA. Only the medicaid director of [or] the medicaid director's written designee may approve exceptions. Exceptions will only be considered for the following:

(i) Emergency services;

(ii) Department-approved out-of-state services;

(iii) Retroactive client eligibility; or

(iv) Other critical department need as determined by the medicaid director or the medicaid director's written designee.

(b) For federally qualified health centers (FQHCs), see WAC 388-548-1200. For rural health clinics (RHCs), see WAC 388-549-1200.

WAC 388-502-0230 Provider payment reviews and ((appeal)) dispute rights.

The department crossed off "drugs, equipment, and/or related supplies" and included a new sentence which explains that "healthcare services" includes "treatment, equipment, related supplies, and drugs." This language is consistent with WAC 388-501-0050.

(1) As authorized by chapters 43.20B and 74.09 RCW, the ((medical assistance administration (MAA))) department monitors and reviews all providers who furnish ((medical, dental, or other)) healthcare services, drugs, equipment and/or related supplies to eligible ((medical assistance)) clients. For the purposes of this section, healthcare services includes treatment, equipment, related supplies, and drugs. ((MAA)) The department may review all documentation and/or data related to payments made to providers for healthcare services, drugs, equipment and/or supplies for eligible clients and determine((s)) whether the providers are complying with the rules and regulations of the program(s) ((and providing appropriate quality of care, and recovers any identified overpayments)).

A final cost-benefit analysis is available by contacting Andi Hanson/Barbara Lantz, P.O. Box 45530, Olympia, WA 98504-5530, phone (360) 725-1616 or (360) 725-1640, fax (360) 586-9727, e-mail

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 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 10, Amended 4, 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 10, Amended 4, Repealed 0.

Date Adopted: May 9, 2011.

Susan N. Dreyfus


Reviser's note: The material contained in this filing exceeded the page-count limitations of WAC 1-21-040 for appearance in this issue of the Register. It will appear in the 11-12 issue of the Register.

Washington State Code Reviser's Office