HEALTH CARE AUTHORITY

(Medicaid Program)

(1) The medicaid agency covers health care services, equipment, and supplies listed in this chapter, according to agency rules and subject to the limitations and requirements in this chapter, when they are:

(a) Within the scope of an eligible client's ((medical assistance)) Washington apple health program. Refer to WAC 182-501-0060 and 182-501-0065; and

(b) Medically necessary as defined in WAC 182-500-0070.

(2) The agency evaluates a request for a service that is in a covered category under the provisions of WAC ((182-501-0065)) 182-501-0165.

(3) The agency evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions as described in WAC 182-501-0169.

(4) The agency covers the following physician-related services and health care professional services, subject to the conditions in subsections (1), (2), and (3) of this section:

(a) Alcohol and substance misuse counseling (refer to WAC 182-531-1710);

(b) Allergen immunotherapy services;

(((b))) (c) Anesthesia services;

(((c))) (d) Dialysis and end stage renal disease services (refer to chapter 182-540 WAC);

(((d))) (e) Emergency physician services;

(((e))) (f) ENT (ear, nose, and throat) related services;

(((f))) (g) Early and periodic screening, diagnosis, and treatment (EPSDT) services (refer to WAC 182-534-0100);

(((g))) (h) Habilitative services (refer to WAC 182-545-400);

(i) Reproductive health services (refer to chapter 182-532 WAC);

(((h))) (j) Hospital inpatient services (refer to chapter 182-550 WAC);

(((i))) (k) Maternity care, delivery, and newborn care services (refer to chapter 182-533 WAC);

(((j))) (l) Office visits;

(((k))) (m) Vision-related services (refer to chapter 182-544 WAC for vision hardware for clients twenty years of age and younger);

(((l))) (n) Osteopathic treatment services;

(((m))) (o) Pathology and laboratory services;

(((n))) (p) Physiatry and other rehabilitation services (refer to chapter 182-550 WAC);

(((o))) (q) Foot care and podiatry services (refer to WAC 182-531-1300);

(((p))) (r) Primary care services;

(((q))) (s) Psychiatric services((, provided by a psychiatrist));

(((r))) (t) Psychotherapy services ((for children as provided in)) (refer to WAC 182-531-1400);

(((s))) (u) Pulmonary and respiratory services;

(((t))) (v) Radiology services;

(((u))) (w) Surgical services;

(x) Other outpatient physician services.)) (x) Cosmetic, reconstructive, or plastic surgery, and related services and supplies to correct physiological defects (e.g., congenital or as a result of illness or physical trauma), or for mastectomy reconstruction for post cancer treatment;

(5) The agency covers physical examinations for ((medical assistance)) Washington apple health clients only when the physical examination is for one or more of the following:

(a) A screening exam covered by the EPSDT program (see WAC 182-534-0100);

(b) An annual exam for clients of the division of developmental disabilities; or

(c) A screening pap smear, mammogram, or prostate exam.

(6) By providing covered services to a client eligible for ((a medical assistance program)) Washington apple health, a provider who meets the requirements in WAC 182-502-0005(3) accepts the agency's rules and fees which includes federal and state law and regulations, billing instructions, and ((agency issuances)) provider notices.

(1) Except as provided in WAC 182-531-0100 and subsection (2) of this section, the medicaid agency does not cover the following:

(a) Acupuncture, massage, or massage therapy;

(b) Any service specifically excluded by statute;

(c) Care, testing, or treatment of infertility, frigidity, or impotency. This includes procedures for donor ovum, sperm, womb, and reversal of vasectomy or tubal ligation;

(d) Hysterectomy performed solely for the purpose of sterilization;

(e) Cosmetic treatment or surgery, except ((for medically necessary reconstructive surgery to correct defects attributable to trauma, birth defect, or illness)) as provided in WAC 182-531-0100 (4)(x);

(f) Experimental or investigational services, procedures, treatments, devices, drugs, or application of associated services, except when the individual factors of an individual client's condition justify a determination of medical necessity under WAC 182-501-0165;

(g) Hair transplantation;

(h) Marital counseling or sex therapy;

(i) More costly services when the medicaid agency determines that less costly, equally effective services are available;

(j) Vision-related services as follows:

(i) Services for cosmetic purposes only;

(ii) Group vision screening for eyeglasses; and

(iii) Refractive surgery of any type that changes the eye's refractive error. The intent of the refractive surgery procedure is to reduce or eliminate the need for eyeglass or contact lens correction. This refractive surgery does not include intraocular lens implantation following cataract surgery.

(k) Payment for body parts, including organs, tissues, bones and blood, except as allowed in WAC 182-531-1750;

(l) Physician-supplied medication, except those drugs which the client cannot self-administer and therefore are administered by the physician in the physician's office;

(m) Physical examinations or routine checkups, except as provided in WAC 182-531-0100;

(n) Foot care, unless the client meets criteria and conditions outlined in WAC 182-531-1300, as follows:

(i) Routine foot care, such as but not limited to:

(A) Treatment of tinea pedis;

(B) Cutting or removing warts, corns and calluses; and

(C) Trimming, cutting, clipping, or debriding of nails.

(ii) Nonroutine foot care, such as, but not limited to treatment of:

(A) Flat feet;

(B) High arches (cavus foot);

(C) Onychomycosis;

(D) Bunions and tailor's bunion (hallux valgus);

(E) Hallux malleus;

(F) Equinus deformity of foot, acquired;

(G) Cavovarus deformity, acquired;

(H) Adult acquired flatfoot (metatarsus adductus or pes planus);

(I) Hallux limitus.

(iii) Any other service performed in the absence of localized illness, injury, or symptoms involving the foot;

(o) Except as provided in WAC 182-531-1600, weight reduction and control services, procedures, treatments, devices, drugs, products, gym memberships, equipment for the purpose of weight reduction, or the application of associated services((.));

(p) Nonmedical equipment;

(q) Nonemergent admissions and associated services to out-of-state hospitals or noncontracted hospitals in contract areas; and

(r) ((Bilateral cochlear implantation; and

(s) Routine or nonemergency medical and surgical dental services provided by a doctor of dental medicine or dental surgery for clients twenty one years of age and older, except for clients of the developmental disabilities administration in the department of social and health services)) Vaccines recommended or required for the sole purpose of international travel. This does not include routine vaccines administered according to current centers for disease control (CDC) advisory committee on immunization practices (ACIP) immunization schedule for adults and children in the United States.

(2) The medicaid agency covers excluded services listed in (1) of this subsection if those services are mandated under and provided to a client who is eligible for one of the following:

(a) The EPSDT program;

(b) A ((medicaid)) Washington apple health program for qualified medicare beneficiaries (QMBs); or

(c) A waiver program.

(v) Podiatry.)) (1) The health care professionals and health care entities listed in WAC 182-502-0002 and enrolled with the agency can bill for physician-related and health care professional services that are within their scope of practice.

(2) The ((department)) agency does not pay for services performed by any of the ((following practitioners:

(ii) Trained to provide)) health care professionals listed in WAC 182-502-0003.

(3) The ((department)) agency pays ((practitioners listed in subsection (2) of this section)) eligible providers for physician-related services if those services are mandated by, and provided to, clients who are eligible for one of the following:

(a) The EPSDT program;

(b) A ((medicaid)) Washington apple health program for qualified medicare beneficiaries (QMB); or

(c) A waiver program.

(1) The ((department reimburses)) medicaid agency pays providers for laboratory services only when:

(a) The provider is certified according to Title XVII of the Social Security Act (medicare), if required; and

(b) The provider has a clinical laboratory improvement amendment (CLIA) certificate and identification number.

(2) The ((department)) agency includes a handling, packaging, and mailing fee in the reimbursement for lab tests and does not reimburse these separately.

(3) The ((department reimburses only)) agency pays for one blood drawing fee per client, per day. The ((department)) agency allows additional reimbursement for an independent laboratory when it goes to a nursing facility or a private home to obtain a specimen.

(4) The ((department reimburses)) agency pays for only one catheterization for collection of a urine specimen per client, per day.

(5) The ((department reimburses)) agency pays for automated multichannel tests done alone or as a group, as follows:

(a) The provider must bill a panel if all individual tests are performed. If not all tests are performed, the provider must bill individual tests.

(b) If the provider bills one automated multichannel test, the ((department)) agency reimburses the test at the individual procedure code rate, or the internal code maximum allowable fee, whichever is lower.

(c) Tests may be performed in a facility that owns or leases automated multichannel testing equipment. The facility may be any of the following:

(i) A clinic;

(ii) A hospital laboratory;

(iii) An independent laboratory; or

(iv) A physician's office.

(6) The ((department)) agency allows a STAT fee in addition to the maximum allowable fee when a laboratory procedure is performed STAT.

(a) The ((department reimburses)) agency pays for STAT charges for only those procedures identified by the clinical laboratory advisory council as appropriate to be performed STAT.

(b) Tests generated in the emergency room do not automatically justify a STAT order, the physician must specifically order the tests as STAT.

(c) Refer to the fee schedule for a list of STAT procedures.

(7) The ((department reimburses)) agency pays for drug screen charges only when medically necessary and when ordered by a physician as part of a total medical evaluation.

(8) The ((department)) agency does not ((reimburse)) pay for drug screens for clients in the division of ((alcohol and substance abuse (DASA)-contracted)) behavioral health and recovery (DBHR) within the department of social and health services (DSHS)-contracted methadone treatment programs. These are reimbursed through a contract issued by ((DASA)) DBHR DSHS.

(9) The ((department)) agency does not ((cover)) pay for drug screens to monitor ((any of the following:

(a))) for program compliance in either a residential or outpatient drug or alcohol treatment program((;

(c) Suspected drug use by clients in a residential setting, such as a group home)).

(10) The ((department)) agency may require a drug or alcohol screen in order to determine a client's suitability for a specific test.

(11) An independent laboratory must bill the ((department)) agency directly. The ((department)) agency does not ((reimburse)) pay a medical practitioner for services referred to or performed by an independent laboratory.

(l) The ((department reimburses)) medicaid agency pays eligible providers for the following:

(a) Two calls per month for routine medical conditions for a client residing in a nursing facility; and((.))

(b) One call per noninstitutionalized client, per day, for an individual physician, except for valid call-backs to the emergency room per WAC ((388-531-0500)) 182-531-0500.

(2) The provider must provide justification based on medical necessity at the time of billing for visits in excess of subsection (l) of this section and follow the requirements in WAC 182-501-0169.

(3) See ((physician)) the agency's physician-related services billing instructions for procedures that are included in the office call and that cannot be billed separately.

(4) Using selected diagnosis codes, the ((department)) agency reimburses the provider at the appropriate level of physician office call for history and physical procedures in conjunction with dental surgery services performed in an outpatient setting.

(5) The ((department)) agency may reimburse providers for injection procedures and/or injectable drug products only when:

(a) The injectable drug is administered during an office visit; and

(b) The injectable drug used is from office stock and which was purchased by the provider from a ((pharmacist or)) pharmacy, drug manufacturer ((as described in WAC 388-530-1200)), or drug wholesaler.

(6) The ((department)) agency does not reimburse a prescribing provider for a drug when a pharmacist dispenses the drug.

(7) The ((department)) agency does not reimburse the prescribing provider for an immunization when the immunization material is received from the department of health; the ((department)) agency does reimburse an administrative fee. If the immunization is given in a health department and is the only service provided, the ((department)) agency reimburses a minimum E&M service.

(8) The ((department)) agency reimburses immunizations at estimated acquisition costs (EAC) when the immunizations are not part of the vaccine for children program. The ((department)) agency reimburses a separate administration fee for these immunizations. Covered immunizations are listed in the fee schedule. Refer to WAC 182-531-0150 (1)(r) for vaccines recommended or required for the sole purpose of international travel.

(9) The ((department)) agency reimburses therapeutic and diagnostic injections subject to certain limitations as follows:

(a) The ((department)) agency does not pay separately for the administration of intra-arterial and intravenous therapeutic or diagnostic injections provided in conjunction with intravenous infusion therapy services. The ((department)) agency does pay separately for the administration of these injections when they are provided on the same day as an E&M service. The ((department)) agency does not pay separately an administrative fee for injectables when both E&M and infusion therapy services are provided on the same day. The ((department)) agency reimburses separately for the drug(s).

(b) The ((department)) agency does not pay separately for subcutaneous or intramuscular administration of antibiotic injections provided on the same day as an E&M service. If the injection is the only service provided, the ((department)) agency pays an administrative fee. The ((department)) agency reimburses separately for the drug.

(c) The ((department)) agency reimburses injectable drugs at acquisition cost. The provider must document the name, strength, and dosage of the drug and retain that information in the client's file. The provider must provide an invoice when requested by the ((department)) agency. This subsection does not apply to drugs used for chemotherapy; see subsection (11) in this section for chemotherapy drugs.

(d) The provider must submit a manufacturer's invoice to document the name, strength, and dosage on the claim form when billing the ((department)) agency for the following drugs:

(i) Classified drugs where the billed charge to the ((department)) agency is over one thousand, one hundred dollars; and

(ii) Unclassified drugs where the billed charge to the ((department)) agency is over one hundred dollars. This does not apply to unclassified antineoplastic drugs.

(10) The ((department)) agency reimburses allergen immunotherapy only as follows:

(a) Antigen/antigen preparation codes are reimbursed per dose.

(b) When a single client is expected to use all the doses in a multiple dose vial, the provider may bill the total number of doses in the vial at the time the first dose from the vial is used. When remaining doses of a multiple dose vial are injected at subsequent times, the ((department)) agency reimburses the injection service (administration fee) only.

(c) When a multiple dose vial is used for more than one client, the provider must bill the total number of doses provided to each client out of the multiple dose vial.

(d) The ((department)) agency covers the antigen, the antigen preparation, and an administration fee.

(e) The ((department)) agency reimburses a provider separately for an E&M service if there is a diagnosis for conditions unrelated to allergen immunotherapy.

(f) The ((department)) agency reimburses for RAST testing when the physician has written documentation in the client's record indicating that previous skin testing failed and was negative.

(11) The ((department)) agency reimburses for chemotherapy drugs:

(a) Administered in the physician's office only when:

(i) The physician personally supervises the E&M services furnished by office medical staff; and

(ii) The medical record reflects the physician's active participation in or management of course of treatment.

(b) At established maximum allowable fees that are based on the medicare pricing method for calculating the estimated acquisition cost (EAC), or maximum allowable cost (MAC) when generics are available;

(c) For unclassified antineoplastic drugs, the provider must submit the following information on the claim form:

(i) The name of the drug used;

(ii) The dosage and strength used; and

(iii) The national drug code (((NCD) [NDC])) (NDC).

(12) Notwithstanding the provisions of this section, the ((department)) agency reserves the option of determining drug pricing for any particular drug based on the best evidence available to the ((department)) agency, or other good and sufficient reasons (e.g., fairness/equity, budget), regarding the actual cost, after discounts and promotions, paid by typical providers nationally or in Washington state.

(13) The ((department)) agency may request an invoice as necessary.

(1) The ((department reimburses osteopathic)) medicaid agency pays for manipulative therapy (((OMT))) only when ((OMT is)):

(a) Provided by an osteopathic physician licensed under chapter (( 18.71 RCW.

(2) The department reimburses OMT only when the provider bills)) 18.57 RCW or naturopathic physicians licensed under chapter 18.36A RCW; and

(b) Billed using the appropriate CPT codes that involve the number of body regions involved.

(((3))) (2) The ((department)) agency allows an osteopathic physician or naturopathic physician to bill the ((department)) agency for an evaluation and management (E&M) service in addition to the ((OMT)) manipulative therapy when one of the following apply:

(a) The physician diagnoses the condition requiring manipulative therapy and provides it during the same visit;

(b) The existing related diagnosis or condition fails to respond to manipulative therapy or the condition significantly changes or intensifies, requiring E&M services beyond those included in the manipulation codes; or

(c) The physician treats the client during the same encounter for an unrelated condition that does not require manipulative therapy.

(((4))) (3) The ((department limits reimbursement)) agency pays for ten manipulations ((to ten)) per client, per calendar year. ((Reimbursement)) The agency evaluates a request for manipulations that is in excess of the limitations or restrictions according to WAC 182-501-0169. Payment for each manipulation includes a brief evaluation as well as the manipulation.

(((5))) (4) The ((department)) agency does not ((reimburse)) pay for physical therapy services performed by osteopathic physicians or naturopathic physicians.

(12) Accepting payment under more than one contract or agreement with the department for the same service for the same client constitutes duplication of payment. If a client is provided services under multiple contracts or agreements, each provider must maintain documentation identifying the type of service provided and the contract or agreement under which it is provided to ensure it is not a duplication of service.)) (1) The mental health services covered in this section are different from the mental health services covered under chapter 388-865 WAC, Community mental health and involuntary treatment programs, administered by the division of behavioral health and recovery within the department of social and health services.

(1) The medicaid agency covers alcohol and substance misuse counseling through screening, brief intervention, and referral to treatment (SBIRT) services when delivered by, or under the supervision of, a qualified licensed physician or other qualified licensed health care professional within the scope of their practice.

(2) SBIRT is a comprehensive, evidence-based public health practice designed to identify, reduce and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. SBIRT can be used to identify people who are at risk for or have some level of substance use disorder which can lead to illness, injury, or other long-term morbidity or mortality. SBIRT services are provided in a wide variety of medical and community health care settings such as primary care centers, hospital emergency rooms, and trauma centers.

(3) The following health care professionals are eligible to become qualified SBIRT providers to deliver SBIRT services or supervise qualified staff to deliver SBIRT services:

(a) Advanced registered nurse practitioners, in accordance with chapters 18.79 RCW and 246-840 WAC;

(b) Chemical dependency professionals, in accordance with chapters 18.205 RCW and 246-811 WAC;

(c) Licensed practical nurses, in accordance with chapters 18.79 RCW and 246-840 WAC;

(d) Mental health counselors, in accordance with chapters 18.225 RCW and 246-809 WAC;

(e) Marriage and family therapists, in accordance with chapters 18.225 RCW and 246-809 WAC;

(f) Independent and advanced social workers, in accordance with chapters 18.225 RCW and 246-809 WAC;

(g) Physicians, in accordance with chapters 18.71 RCW and 246-919 WAC;

(h) Physician assistants, in accordance with chapters 18.71A RCW and 246-918 WAC;

(i) Psychologists, in accordance with chapters 18.83 RCW and 246-924 WAC;

(j) Registered nurses, in accordance with chapters 18.79 RCW and 246-840 WAC;

(k) Dentists, in accordance with chapters 18.260 and 246-817; and

(l) Dental hygienists, in accordance with chapters 18.29 and 246-815 WAC.

(4) To become a qualified SBIRT provider, eligible licensed health care professionals must:

(a) Complete a minimum of four hours of SBIRT training; and

(b) Mail or fax the SBIRT training certificate or other proof of training completion to the agency.

(5) The agency pays for SBIRT as follows:

(a) Screenings, which are included in the reimbursement for the evaluation and management code billed;

(b) Brief interventions, limited to four sessions per client, per provider, per calendar year; and

(c) When billed by one of the following qualified SBIRT health care professionals:

(i) Advanced registered nurse practitioners;

(ii) Mental health counselors;

(iii) Marriage and family therapists;

(iv) Independent and advanced social workers;

(v) Physicians;

(vi) Psychologists;

(vii) Dentists; and

(viii) Dental hygienists.

(6) The agency evaluates a request for additional sessions in excess of the limitations or restrictions according to WAC 182-501-0169.

(7) To be paid for providing alcohol and substance misuse counseling through SBIRT, providers must bill the agency using the agency's published billing instructions.

(1) The medicaid agency covers tobacco cessation counseling when delivered by qualified providers through the agency contracted quitline or during face-to-face office visits for tobacco cessation for pregnant clients.

(2) The agency pays for face-to-face office visits for tobacco cessation counseling for pregnant clients with the following limits:

(a) When provided by physicians, advanced registered nurse practitioners (ARNPs), physician assistants-certified (PA-Cs), naturopathic physicians, and dentists;

(b) Two cessation counseling attempts (or up to eight sessions) are allowed every twelve months. An attempt is defined as up to four cessation counseling sessions.

(3) To be paid for tobacco cessation counseling through SBIRT, providers must bill the agency using the agency's published billing instructions.