WSR 15-14-071
(Washington Apple Health)
[Filed June 26, 2015, 2:40 p.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 15-08-053.
Title of Rule and Other Identifying Information: WAC 182-531-0250 Who can provide and bill for physician-related and health care professional services and 182-531-1900 PaymentGeneral requirements for physician-related services.
Hearing Location(s): Health Care Authority (HCA), Cherry Street Plaza Building, Sue Crystal Conference Room 106A, 626 8th Avenue, Olympia, WA 98504 (metered public parking is available street side around building. A map is available at or directions can be obtained by calling (360) 725-1000), on August 4, 2015, at 10:00 a.m.
Date of Intended Adoption: Not sooner than August 5, 2015.
Submit Written Comments to: HCA Rules Coordinator, P.O. Box 45504, Olympia, WA 98504-5504, delivery 626 8th Avenue, Olympia, WA 98504, e-mail, fax (360) 586-9727, by 5:00 p.m. on August 4, 2015.
Assistance for Persons with Disabilities: Contact Kelly Richters by July 30, 2015, TTY (800) 848-5429 or (360) 725-1307 or e-mail
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: To establish in rule the agency's policy for payment of services provided by, or in conjunction with, a resident physician.
Reasons Supporting Proposal: See Purpose above.
Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.
Statute Being Implemented: RCW 41.05.021, 41.05.160.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Wendy Barcus, P.O. Box 42716, Olympia, WA 98504-2716, (360) 725-1306; Implementation and Enforcement: Lisa Humphrey, P.O. Box 45504, Olympia, WA 98504-5504, (360) 725-1617.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The agency has determined that the proposed filing does not impose a disproportionate cost impact on small businesses or nonprofits.
A cost-benefit analysis is not required under RCW 34.05.328. RCW 34.05.328 does not apply to HCA rules unless requested by the joint administrative rules review committee or applied voluntarily.
June 26, 2015
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 15-03-041, filed 1/12/15, effective 2/12/15)
WAC 182-531-0250 Who can provide and bill for physician-related and health care professional services.
(1) The health care professionals and health care entities listed in WAC 182-502-0002 and enrolled with the medicaid agency can bill for physician-related and health care professional services that are within their scope of practice.
(2) The agency pays for services provided by, or in conjunction with, a resident physician when:
(a) The services are billed under the teaching hospital's national provider identifier (NPI) or the supervising physician's NPI;
(b) The performing provider is identified on the claim under the teaching or resident physician's NPI; and
(c) The services are provided and billed according to this chapter and chapters 182-501 and 182-502 WAC.
(3) The agency does not pay for services performed by any of the health care professionals listed in WAC 182-502-0003.
(((3))) (4) The agency pays eligible providers for physician-related services and health care professional services if those services are mandated by, and provided to((,)) clients who are eligible for, one of the following:
(a) The early and periodic screening, diagnosis, and treatment (EPSDT) program;
(b) A Washington apple health program for qualified medicare beneficiaries (QMB); or
(c) A waiver program.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-531-1900 ((Reimbursement)) PaymentGeneral requirements for physician-related services.
(1) The ((department reimburses)) medicaid agency pays physicians and related providers for covered services provided to eligible clients on a fee-for-service basis, subject to the exceptions, restrictions, and other limitations listed in this chapter and other published issuances.
(2) ((In order to be reimbursed)) To receive payment, physicians must bill the ((department)) agency according to the conditions of payment under WAC ((388-501-0150 and other issuances)) 182-502-0100.
(3) The ((department)) agency does not separately reimburse certain administrative costs or services. The ((department)) agency considers these costs to be included in the ((reimbursement)) payment. These costs and services include the following:
(a) Delinquent payment fees;
(b) Educational supplies;
(c) Mileage;
(d) Missed or canceled appointments;
(e) Reports, client charts, insurance forms, and copying expenses;
(f) Service charges;
(g) Take home drugs; and
(h) Telephoning (e.g., for prescription refills).
(4) The ((department)) agency does not routinely pay for procedure codes which have a "#" or "NC" indicator in the fee schedule. The ((department)) agency reviews these codes for conformance to medicaid program policy only as an exception to policy or as a limitation extension. See WAC ((388-501-0160 and 388-501-0165)) 182-501-0160 and 182-501-0165.