PROPOSED RULES
SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)
Original Notice.
Preproposal statement of inquiry was filed as WSR 99-20-048.
Title of Rule: Repealing WAC 388-87-015 Billing limitations and new section WAC 388-502-0150 Time limits for providers to bill MAA.
Purpose: The department originally intended to rewrite WAC 388-87-015 solely to comply with the Governor's Executive Order 97-02 on regulatory reform. However, since the department is in the process of consolidating its rule in one area, it was decided to incorporate the policies in WAC 388-87-015 into chapter 388-502 WAC and repeal WAC 388-87-015. The new rule reflects long-standing program policy; it has been written to be more readable and has been reviewed in consultation with the regulated community.
Statutory Authority for Adoption: RCW 74.08.090, 42 C.F.R. 447.45.
Statute Being Implemented: 42 C.F.R. 447.45.
Summary: The department is consolidating its rules into one area of WAC. WAC 388-87-015 is being repealed and the policy is being moved to WAC 388-502-0150. The new rule does not make any changes in the programs's operational policy.
Reasons Supporting Proposal: To ensure that department rules reflect current and accurate department policy, to eliminate confusion by consolidating related rules and to comply with the Governor's Executive Order 97-02 on regulatory reform.
Name of Agency Personnel Responsible for Drafting: L. Mike Freeman, RIP, 925 Plum Street, Olympia, WA 98501, (360) 725-1350; Implementation and Enforcement: Ann Lawrence, PRU, 817 S.E. 8th Avenue, Olympia, WA 98501, (360) 725-1020.
Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.
Rule is necessary because of federal law, 42 C.F.R. 447.45.
Explanation of Rule, its Purpose, and Anticipated Effects: The rule implements federal requirements for timely receipt of claims for payment under the programs of MAA. The time limits for billing MAA are more generous than those of most other payors of health care claims.
Proposal Changes the Following Existing Rules: The proposal repeals WAC 388-87-015, and moves the policy to WAC 388-502-0150. The proposed new rules clarify and provide greater detail about long-standing program policy. The proposed rules do not place additional restrictions on the regulated community or increase the costs to clients, contractors or the department.
No small business economic impact statement has been prepared under chapter 19.85 RCW. MAA reviewed these proposed rules and concluded that the impact of these rewritten rules will not place "a more than minor impact on businesses."
RCW 34.05.328 does not apply to this rule adoption. The proposed rules do not meet the definition of "a significant legislative rule."
Hearing Location: Lacey Government Center (behind Tokyo Bento Restaurant), 1009 College Street S.E., Room 104-B, Lacey, WA 98503, on May 23, 2000, at 10:00 a.m.
Assistance for Persons with Disabilities: Contact Paige Wall by May 12, 2000, phone (360) 664-6094, TDD (360) 664-6178, e-mail wallpg@dshs.wa.gov.
Submit Written Comments to: Identify WAC Numbers, Paige Wall, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by May 23, 2000.
Date of Intended Adoption: Not sooner than May 24, 2000.
April 10, 2000
Marie Myerchin-Redifer, Manager
Rules and Policies Assistance Unit
2666.6(1) Providers may bill the medical assistance administration (MAA) for covered services provided to eligible clients.
(1) MAA requires providers to submit an initial claim, be assigned an internal control number (ICN), and make all adjustments to claims in a timely manner. MAA has three timeliness standards:
(a) For initial claims, see subsections (3), (4), (5), and (6) of this section;
(b) For resubmitted claims other than prescription drug claims, see subsections (7) and (8) of this section; and
(c) For resubmitted prescription drug claims, see subsections (9) and (10) of this section.
(2) The provider must submit claims to MAA as described in MAA's billing instructions.
(3) MAA requires providers to obtain an ICN for an initial claim within three hundred sixty-five days from any of the following:
(a) The date the provider furnishes the service to the eligible client;
(b) The date a final fair hearing decision is entered that impacts the particular claim;
(c) The date a court orders MAA to cover the service; or
(d) The date the department certifies a client eligible under delayed certification criteria.
(4) MAA may grant exceptions to the three hundred sixty-five-day time limit for initial claims when billing delays are caused by either of the following:
(a) The department's certification of a client for a retroactive period; or
(b) The provider proves to MAA's satisfaction that there are other extenuating circumstances.
(5) MAA requires providers to bill known third parties for services. See WAC 388-501-0200 for exceptions. Providers must meet the timely billing standards of the liable third parties in addition to MAA's billing limits.
(6) When a client is covered by both Medicare and MAA, the provider must bill Medicare for the service before billing Medicaid. If Medicare:
(a) Pays the claim the provider must bill MAA within six months of the date Medicare processes the claim; or
(b) Denies payment of the claim, MAA requires the provider to meet the three hundred sixty-five-day requirement for timely initial claims as described in subsection (3) of this section.
(7) MAA allows providers to resubmit, modify, or adjust any claim, other than a prescription drug claim, with a timely ICN within thirty-six months of the date the service was provided to the client. This applies to any claim, other than a prescription drug claim, that met the time limits for an initial claim, whether paid or denied. MAA does not accept any claim for resubmission, modification, or adjustment after the thirty-six-month period ends.
(8) The thirty-six-month period described in subsection (7) of this section does not apply to overpayments that a provider must refund to the department. After thirty-six months, MAA does not allow a provider to refund overpayments by claim adjustment; a provider must refund overpayments by a negotiable financial instrument, such as a bank check.
(9) MAA allows providers to resubmit, modify, or adjust any prescription drug claim with a timely ICN within fifteen months of the date the service was provided to the client. After fifteen months, MAA does not accept any prescription drug claim for resubmission, modification or adjustment.
(10) The fifteen-month period described in subsection (9) of this section does not apply to overpayments that a prescription drug provider must refund to the department. After fifteen months a provider must refund overpayments by a negotiable financial instrument, such as a bank check.
(11) MAA does not allow a provider or any provider's agent to bill a client or a client's estate when the provider fails to meet the requirements of this section, resulting in the claim not being paid by MAA.
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Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
REPEALER
The following section of the Washington Administrative Code is repealed:
| WAC 388-87-015 | Billing limitations. |