WSR 15-23-060 PROPOSED RULES HEALTH CARE AUTHORITY (Washington Apple Health) [Filed November 13, 2015, 1:28 p.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 15-07-046.
Title of Rule and Other Identifying Information: WAC 182-550-4690 Authorization requirements and utilization review for hospitals eligible for CPE payments.
Hearing Location(s): Health Care Authority (HCA), Cherry Street Plaza Building, Conference Room, 626 8th Avenue, Olympia, WA 98504 (metered public parking is available street side around building. A map is available at http://www.hca.wa.gov/documents/directions_to_csp.pdf or directions can be obtained by calling (360) 725-1000), on December 22, 2015, at 10:00 a.m.
Date of Intended Adoption: Not sooner than December 23, 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 arc@hca.wa.gov, fax (360) 586-9727, by December 22, 2015.
Assistance for Persons with Disabilities: Contact Amber Lougheed by e-mail amber.lougheed@hca.wa.gov, (360) 725-1349, or TTY (800) 848-5429 or 711.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The agency is striking WAC 182-550-4690 (3)(b), which states the agency performs utilization reviews on seven-day readmissions for claims that qualified for diagnosis related group payment before July 1, 2005.
The agency is also striking subsection (5)(c), which refers to WAC 182-550-3000 for inpatient hospital claims that involve a client's seven-day readmission.
This amendment aligns with amendments proposed under WSR 15-19-159, which will implement a population-based, data-driven approach to reduce hospital readmission rates and related costs.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: HCA, governmental.
Name of Agency Personnel Responsible for Drafting: Melinda Froud, P.O. Box 42716, Olympia, WA 98504-2716, (360) 725-1408; Implementation and Enforcement: Gail Kreiger, P.O. Box 45506, Olympia, WA 98504-5506, (360) 725-1681.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The proposed filing does not create a disproportionate impact on small businesses.
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.
November 13, 2015
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 15-18-065, filed 8/27/15, effective 9/27/15)
WAC 182-550-4690 Authorization requirements and utilization review for hospitals eligible for CPE payments.
This section does not apply to psychiatric certified public expenditure (CPE) inpatient hospital admissions. See WAC 182-550-2600.
(1) CPE inpatient hospital claims submitted to the medicaid agency must meet all authorization and program requirements in WAC and current agency-published issuances.
(2) The agency performs utilization reviews of inpatient hospital:
(a) Admissions under the requirements of 42 C.F.R. 456, subparts A through C; and
(b) Claims for compliance with medical necessity, appropriate level of care and the agency's (or an agency designee's) established length of stay (LOS) standards.
(3) For CPE inpatient admissions before August 1, 2007, the agency performs utilization reviews((:
(a))) using the professional activity study (PAS) length of stay (LOS) standard in WAC 182-550-4300 on claims that qualified for ratio of costs-to-charges (RCC) payment before July 1, 2005.
(((b) On seven-day readmissions according to the diagnosis related group (DRG) payment method described in WAC 182-550-3000 for claims that qualified for DRG payment before July 1, 2005.))
(4) For claims identified in this subsection, the agency may request a copy of the client's hospital medical records and itemized billing statements. The agency sends written notification to the hospital detailing the agency's findings. Any day of a client's hospital stay that exceeds the LOS standard:
(a) Is paid under a non-DRG payment method if the agency determines it to be medically necessary for the client at the acute level of care;
(b) Is paid as an administrative day (see WAC 182-550-1050 and 182-550-4500(8)) if the agency determines it to be medically necessary for the client at the subacute level of care; and
(c) Is not eligible for payment if the agency determines it was not medically necessary.
(5) For CPE inpatient admissions after July 31, 2007, CPE hospital claims are subject to the same utilization review rules as non-CPE hospital claims.
(a) LOS reviews may be performed under WAC 182-550-4300.
(b) All claims are subject to the agency's medical necessity review under WAC 182-550-1700(2).
(((c) For inpatient hospital claims that involve a client's seven-day readmission, see WAC 182-550-3000.))
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