Title of Rule: Amending WAC 388-539-0550 Coordinated community aids service alternative (CCASA) program, 388-545-300 Occupational therapy, 388-545-500 Physical therapy, 388-545-700 Speech/audiology services, 388-550-1100 Hospital coverage, 388-550-1400 Covered revenue codes for hospital services, 388-550-1700 Hospital services -- Prior approval, 388-550-2200 Transplant requirements -- COE, 388-550-6700 Hospital services provided out-of-state, 388-555-1150 Eligible providers, 388-555-1200 Provider requirements, and 388-556-0400 Limitations on services available to recipients of categorically needy medical assistance.

Purpose: To correct Medical Assistance Administration (MAA) rules that contain cross-references to rules that have been renumbered or repealed and written into new chapters. MAA recently reorganized and rewrote most of its rules so they are located in the same area of Title 388 WAC. In doing so, some cross-references to rules are now incorrect; this proposal updates those cross-references so users may be referred to the correct rule.

Statutory Authority for Adoption: RCW 74.08.090.

Statute Being Implemented: RCW 74.08.090.

Summary: This proposal corrects cross-references to rules that have been renumbered or repealed and written into new chapters, due to the recent reorganization of MAA rules in Title 388 WAC.

Reasons Supporting Proposal: To ensure the cross-references in MAA rules refer users to the correct WAC cite.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Ann Myers/DCS/RIP, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1345.

Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: Due to MAAs recent reorganization and rewrite of its rules, several cross-references refer to rules that have been renumbered or repealed when the policy was written into new chapters. This proposal corrects those cross-references by replacing the outdated cross-references with correct WAC numbers.

     The purpose and anticipated effect is to refer users to the correct WAC cite.

Proposal Changes the Following Existing Rules: Due to MAAs recent reorganization and rewrite of its rules, several cross-references refer to rules that have been renumbered or repealed when the policy was written into new chapters. This proposal corrects those cross-references by replacing the outdated cross-references with correct WAC numbers.

September 29, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

(1) The department shall establish payment rates for CCASA program services as defined under WAC ((388-86-018)) 388-539-0500.

     (2) The department shall pay for services after the central authorization unit evaluates the recipient's application for medical appropriateness and the department of health has approved a plan of care.

[00-11-183, recodified as § 388-539-0550, filed 5/24/00, effective 5/24/00.      Statutory Authority: RCW 74.08.090.      90-21-124 (Order 3088), § 388-87-048, filed 10/23/90, effective 11/23/90.]

Reviser's note: The bracketed material preceding the section above was supplied by the code reviser's office.2850.2
AMENDATORY SECTION(Amending WSR 99-16-068, filed 8/2/99, effective 9/2/99)

WAC 388-545-300
Occupational therapy.

(1) The following providers are eligible to enroll with medical assistance administration (MAA) to provide occupational therapy services:

     (a) A licensed occupational therapist;

     (b) A licensed occupational therapy assistant supervised by a licensed occupational therapist; and

     (c) An occupational therapy aide, in schools, trained and supervised by a licensed occupational therapist.

     (2) Clients in the following MAA programs are eligible to receive occupational therapy services described in this chapter:

     (a) Categorically needy;

     (b) Children's health;

     (c) General assistance unemployable (within Washington state or border areas only;

     (d) Alcoholism and drug addiction treatment and support act (ADATSA) (within Washington state or border areas only);

     (e) Medically indigent program for emergency hospital-based services only; or

     (f) Medically needy program only when the client is either:

     (i) Twenty years of age or younger and referred by a screening provider under the early and periodic screening, diagnosis and treatment program (healthy kids program) as described in chapter 388-534 WAC ((388-86-027)); or

     (ii) Receiving home health care services as described in ((WAC 388-86-045)) chapter 388-551 WAC, subchapter II.

     (3) Occupational therapy services received by MAA eligible clients must be provided:

     (a) As part of an outpatient treatment program for adults and children;

     (b) By a home health agency as described under ((WAC 388-86-045)) chapter 388-551 WAC, subchapter II;

     (c) As part of the physical medicine and rehabilitation (PM&R) program as described in WAC ((388-86-112)) 388-550-2551;

     (d) By a neurodevelopmental center;

     (e) By a school district or educational service district as part of an individual education program or individualized family service plan as described in WAC ((388-86-022)) 388-537-0100; or

     (f) When prescribed by a provider for clients age twenty-one or older. The therapy must:

     (i) Prevent the need for hospitalization or nursing home care;

     (ii) Assist a client in becoming employable;

     (iii) Assist a client who suffers from severe motor disabilities to obtain a greater degree of self-care or independence; or

     (iv) Be a part of a treatment program intended to restore normal function of a body part following injury, surgery, or prolonged immobilization.

     (4) MAA pays only for covered occupational therapy services listed in this section when they are:

     (a) Within the scope of an eligible client's medical care program;

     (b) Medically necessary, when prescribed by a provider; and

     (c) Begun within thirty days of the date prescribed.

     (5) MAA covers the following occupational therapy services per client, per calendar year:

     (a) Unlimited occupational therapy program visits for clients twenty years of age or younger;

     (b) One occupational therapy evaluation. The evaluation is in addition to the twelve program visits allowed per year;

     (c) Two durable medical equipment needs assessments. The assessments are in addition to the twelve program visits allowed per year;

     (d) Twelve occupational therapy program visits;

     (e) Twenty-four additional outpatient occupational therapy program visits when the diagnosis is any of the following:

     (i) A medically necessary condition for developmentally delayed clients;

     (ii) Surgeries involving extremities, including:

     (A) Fractures; or

     (B) Open wounds with tendon involvement;

     (iii) Intracranial injuries;

     (iv) Burns;

     (v) Traumatic injuries;

     (f) Twenty-four additional occupational therapy program visits following a completed and approved inpatient PM&R program. In this case, the client no longer needs nursing services but continues to require specialized outpatient therapy for any of the following:

     (i) Traumatic brain injury (TBI);

     (ii) Spinal cord injury (paraplegia and quadriplegia);

     (iii) Recent or recurrent stroke;

     (iv) Restoration of the levels of function due to secondary illness or loss from multiple sclerosis (MS);

     (v) Amyotrophic lateral sclerosis (ALS);

     (vi) Cerebral palsy (CP);

     (vii) Extensive severe burns;

     (viii) Skin flaps for sacral decubitus for quads only;

     (ix) Bilateral limb loss; or

     (x) Acute, infective polyneuritis (Guillain-Barre' syndrome).

     (g) Additional medically necessary occupational therapy services, regardless of the diagnosis, must be approved by MAA.

     (6) MAA will pay for one visit to instruct in the application of transcutaneous neurostimulator (TENS), per client, per lifetime.

     (7) MAA does not cover occupational therapy services that are included as part of the reimbursement for other treatment programs. This includes, but is not limited to, hospital inpatient and nursing facility services.

[Statutory Authority: RCW 74.08.090 and 74.09.520.      99-16-068, § 388-545-300, filed 8/2/99, effective 9/2/99.]

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.
AMENDATORY SECTION(Amending WSR 00-04-019, filed 1/24/00, effective 2/24/00)

WAC 388-545-500
Physical therapy.

(1) The following providers are eligible to provide physical therapy services:

     (a) A licensed physical therapist or physiatrist; or

     (b) A physical therapist assistant supervised by a licensed physical therapist.

     (2) Clients in the following MAA programs are eligible to receive physical therapy services described in this chapter:

     (a) Categorically needy (CN);

     (b) Children's health;

     (c) General assistance-unemployable (GA-U) (within Washington state or border areas only);

     (d) Alcoholism and drug addiction treatment and support act (ADATSA) (within Washington state or border areas only);

     (e) Medically indigent program (MIP) for emergency hospital-based services only; or

     (f) Medically needy program (MNP) only when the client is either:

     (i) Twenty years of age or younger and referred under the early and periodic screening, diagnosis and treatment program (EPSDT/healthy kids program) as described in WAC 388-86-027; or

     (ii) Receiving home health care services as described in chapter 388-551 WAC.

     (3) Physical therapy services that MAA eligible clients receive must be provided as part of an outpatient treatment program:

     (a) In an office, home, or outpatient hospital setting;

     (b) By a home health agency as described in chapter 388-551 WAC;

     (c) As part of the acute physical medicine and rehabilitation (acute PM&R) program as described in the acute PM&R subchapter under chapter 388-550 WAC;

     (d) By a neurodevelopmental center;

     (e) By a school district or educational service district as part of an individual education or individualized family service plan as described in WAC ((388-86-022)) 388-537-0100; or

     (f) For disabled children, age two and younger, in natural environments including the home and community settings in which children without disabilities participate, to the maximum extent appropriate to the needs of the child.

     (4) MAA pays only for covered physical therapy services listed in this section when they are:

     (a) Within the scope of an eligible client's medical care program;

     (b) Medically necessary and ordered by a physician, physician's assistant (PA), or an advanced registered nurse practitioner (ARNP);

     (c) Begun within thirty days of the date ordered;

     (d) For conditions which are the result of injuries and/or medically recognized diseases and defects; and

     (e) Within accepted physical therapy standards.

     (5) Providers must document in a client's medical file that physical therapy services provided to clients age twenty-one and older are medically necessary.      Such documentation may include justification that physical therapy services:

     (a) Prevent the need for hospitalization or nursing home care;

     (b) Assist a client in becoming employable;

     (c) Assist a client who suffers from severe motor disabilities to obtain a greater degree of self-care or independence; or

     (d) Are part of a treatment program intended to restore normal function of a body part following injury, surgery, or prolonged immobilization.

     (6) MAA determines physical therapy program units as follows:

     (a) Each fifteen minutes of timed procedure code equals one unit; and

     (b) Each nontimed procedure code equals one unit, regardless of how long the procedure takes.

     (7) MAA does not limit coverage for physical therapy services listed in subsections (8) through (10) of this section if the client is twenty years of age or younger.

     (8) MAA covers, without requiring prior authorization, the following ordered physical therapy services per client, per diagnosis, per calendar year, for clients twenty-one years of age and older:

     (a) One physical therapy evaluation.      The evaluation is in addition to the forty-eight program units allowed per year;

     (b) Forty-eight physical therapy program units;

     (c) Ninety-six additional outpatient physical therapy program units when the diagnosis is any of the following:

     (i) A medically necessary condition for developmentally delayed clients;

     (ii) Surgeries involving extremities, including:

     (A) Fractures; or

     (B) Open wounds with tendon involvement.

     (iii) Intracranial injuries;

     (iv) Burns;

     (v) Traumatic injuries;

     (vi) Meningomyelocele;

     (vii) Down's syndrome;

     (viii) Cerebral palsy; or

     (ix) Symptoms involving nervous and musculoskeletal systems and lack of coordination;

     (d) Two durable medical equipment (DME) needs assessments. The assessments are in addition to the forty-eight physical therapy program units allowed per year.      Two program units are allowed per DME needs assessment; and

     (e) One wheelchair needs assessment in addition to the two durable medical needs assessments.      The assessment is in addition to the forty-eight physical therapy program units allowed per year.      Four program units are allowed per wheelchair needs assessment.

     (f) The following services are allowed, per day, in addition to the forty-eight physical therapy program units allowed per year:

     (i) Two program units for orthotics fitting and training of upper and/or lower extremities.

     (ii) Two program units for checkout for orthotic/prosthetic use.

     (iii) One muscle testing procedure.      Muscle testing procedures cannot be billed in combination with each other.

     (g) Ninety-six additional physical therapy program units are allowed following a completed and approved inpatient acute PM&R program.      In this case, the client no longer needs nursing services but continues to require specialized outpatient physical therapy for any of the following:

     (i) Traumatic brain injury (TBI);

     (ii) Spinal cord injury (paraplegia and quadriplegia);

     (iii) Recent or recurrent stroke;

     (iv) Restoration of the levels of functions due to secondary illness or loss from multiple sclerosis (MS);

     (v) Amyotrophic lateral sclerosis (ALS);

     (vi) Cerebral palsy (CP);

     (vii) Extensive severe burns;

     (viii) Skin flaps for sacral decubitus for quadriplegics only;

     (ix) Bilateral limb loss;

     (x) Open wound of lower limb; or

     (xi) Acute, infective polyneuritis (Guillain-Barre' syndrome).

     (9) For clients age twenty-one and older, MAA covers physical therapy services which exceed the limitations established in subsection (8) of this section if the provider requests prior authorization and MAA approves the request.

     (10) MAA will pay for one visit to instruct in the application of transcutaneous neurostimulator (TENS) per client, per lifetime.

     (11) Duplicate services for occupational therapy and physical therapy are not allowed for the same client when both providers are performing the same or similar procedure(s).

     (12) MAA does not cover physical therapy services that are included as part of the reimbursement for other treatment programs.      This includes, but is not limited to, hospital inpatient and nursing facility services.

     (13) MAA does not cover physical therapy services performed by a physical therapist in an outpatient hospital setting when the physical therapist is not employed by the hospital. Reimbursement for services must be billed by the hospital.

[Statutory Authority: RCW 74.08.090 and 74.09.520.      00-04-019, § 388-545-500, filed 1/24/00, effective 2/24/00.]

(1) The following providers are eligible to enroll with medical assistance administration (MAA) to provide, and be reimbursed for, speech/audiology services:

     (a) A speech-language pathologist who has been granted a certificate of clinical competence by the American Speech, Hearing and Language Association;

     (b) A speech-language pathologist who has completed the equivalent educational and work experience necessary for such a certificate;

     (c) An audiologist who is appropriately licensed or registered to perform audiology services within their state of residence; and

     (d) School districts or educational service districts. Services must be noted in the client's individual educational program or individualized family service plan as described under WAC ((388-86-022)) 388-537-0100.

     (2) Clients in the following MAA programs are eligible to receive speech/audiology services described in this chapter:

     (a) Categorically needy, children's health, general assistance unemployable, and alcoholism and drug addiction treatment and support act (ADATSA) programs within Washington state or border areas only; or

     (b) Medically needy program only when the client is either:

     (i) Twenty years of age or under; or

     (ii) Receiving home health care services as described under ((WAC 388-86-045)) chapter 388-551 WAC, subchapter II;

     (c) Medically indigent program only for emergency hospital-based services.

     (3) MAA pays only for covered speech/audiology services listed in this section when they are:

     (a) Within the scope of an eligible client's medical care program;

     (b) For conditions which are the result of medically recognized diseases and defects; and

     (c) Medically necessary, as determined by a health professional.

     (4) The following speech/audiology services are covered per client, per calendar year, per provider:

     (a) Unlimited speech/audiology program visits for clients twenty years of age and younger;

     (b) One medical diagnostic evaluation for clients twenty-one years of age and older. The medical diagnostic evaluation is in addition to the twelve program visits allowed per year;

     (c) One second medical diagnostic evaluation at the time of discharge for any of the following:

     (i) Anoxic brain damage;

     (ii) Acute, ill-defined, cerebrovascular disease;

     (iii) Subarachnoid, subdural, and extradural hemorrhage following injury; or

     (iv) Intracranial injury of other and unspecified nature;

     (d) Twelve speech/audiology program visits for clients twenty-one years of age and older;

     (e) Twenty-four additional speech/audiology visits if the speech/audiology service is for any of the following:

     (i) Medically necessary conditions for developmentally delayed clients;

     (ii) Neurofibromatosis;

     (iii) Severe oral or motor dyspraxia;

     (iv) Amyotrophic lateral sclerosis (ALS);

     (v) Multiple sclerosis;

     (vi) Cerebral palsy;

     (vii) Quadriplegia;

     (viii) Acute, infective polyneuritis (Guillain-Barre' syndrome);

     (ix) Acute, but ill-defined, cerebrovascular disease;

     (x) Meningomyelocele;

     (xi) Cleft palate and cleft lip;

     (xii) Down's syndrome;

     (xiii) Lack of coordination;

     (xiv) Severe aphasia;

     (xv) Severe dysphagia;

     (xvi) Fracture of the:

     (A) Vault or base of the skull;

     (B) Multiple fracture involving skull or face with other bones;

     (C) Cervical column;

     (D) Larynx and trachea; or

     (E) Other and unqualified skull fractures;

     (xvii) Head injuries as follows:

     (A) Cerebral laceration and contusion;

     (B) Subarachnoid, subdural, and extradural hemorrhage following injury;

     (C) Other and unspecified intracranial hemorrhage following injury;

     (D) Injury to blood vessels of the head and neck; or

     (E) Intracranial injury of other second unspecified nature;

     (xvii) Burns of:

     (A) The face, head, and neck, when severe;

     (B) Multiple, specified sites; or

     (C) Internal organs;

     (xix) Cervical spinal cord injury without evidence of spinal bone injury; or

     (xx) Other speech disturbances (e.g., severe dysarthria).

     (f) Additional medically necessary speech/audiology program visits beyond the initial twelve visits and additional twenty-four visits for clients twenty-one years of age and older if approved by MAA.

     (5) MAA limits:

     (a) Caloric vestibular testing to four units for each ear, and

     (b) Sinusoidal vertical axis rotational testing to three units for each direction.

     (6) MAA does not cover speech/audiology services that are included as part of the reimbursement for other treatment programs. This includes, but is not limited to, hospital inpatient and nursing facility services.

[Statutory Authority: RCW 74.08.090 and 74.09.520.      99-16-071, § 388-545-700, filed 8/2/99, effective 9/2/99.]

(1) Admission of a medical care client to a hospital shall be covered only when the admission is requested by the client's attending physician.      For nonemergent hospital admissions, "attending physician" shall mean the client's primary care provider, or the primary provider of care to the patient at the time of hospitalization.      For emergent admissions, "attending physician" shall mean the staff member who has hospital privileges who evaluates the client's medical condition upon the client's arrival at the hospital.

     (2) In areas where the choice of hospitals is limited by managed care or selective contracting, the department shall not be responsible for payment under fee-for-service for hospital care and/or services:

     (a) Provided to managed care clients enrolled in the department's managed care plan, unless the services are excluded from the health carrier's capitation contract with the department and are covered under the medical assistance program; or

     (b) Received by a medical care client from a nonparticipating hospital in a selective contracting area (SCA) unless exclusions in WACs 388-550-4600 and 388-550-4700 apply.

     (3) The department shall provide chemical-dependent pregnant Medicaid clients up to twenty-six days of inpatient hospital care for hospital-based detoxification, medical stabilization, and drug treatment when:

     (a) An alcohol, drug addiction and treatment support act assessment center verifies the need for the inpatient care; and

     (b) The hospital chemical dependency treatment unit is certified by the division of alcohol and substance abuse.

     See WAC 388-550-6250 for outpatient hospital services for chemical-dependent pregnant Medicaid clients.

     (4) The department shall cover medically necessary services provided to eligible clients in a hospital setting for the care or treatment of teeth, jaws, or structures directly supporting the teeth:

     (a) If the procedure requires hospitalization; and

     (b) A physician or dentist gives or directly supervises such services.

     (5) The department shall pay hospitals for services provided in special care units when the provisions of WAC 388-550-2900 (9)(c) are met.

     (6) All services shall be subject to review and approval as stated in WAC ((388-87-025)) 388-501-0050.

     (7) For inpatient psychiatric admissions, whether voluntary or involuntary, see chapter 246-318 WAC.

[Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020.      98-01-124, § 388-550-1100, filed 12/18/97, effective 1/18/98.]

(1) The department shall cover the following revenue code categories for both inpatient and outpatient hospitalizations:

     (a) "Pharmacy," except that:

     (i) Subcategories "take-home drugs," "experimental drugs," and "other pharmacy" are not covered; and

     (ii) Subcategory "nonprescription" is covered for inpatients only;

     (b) "Intravenous (IV) therapy," except subcategory "other IV therapy";

     (c) "Medical/surgical supplies and devices," except for the following subcategories:

     (i) "Take home supplies";

     (ii) "Prosthetic devices";

     (iii) "Oxygen - take home"; and

     (iv) "Other supplies/devices."

     (d) "Oncology," except subcategory "other oncology";

     (e) "Respiratory services," except subcategory "other respiratory services";

     (f) Subcategories "general classification" and "minor surgery" under the "operating room services" category;

     (g) "Anesthesia," except subcategories "acupuncture" and "other anesthesia";

     (h) "Blood storage and processing," except subcategory "other blood storage and processing";

     (i) "Other imaging services," except subcategory "other image services";

     (j) "Emergency room," except subcategory "other emergency room";

     (k) "Pulmonary function," except subcategory "other pulmonary function";

     (l) "Cardiology," except subcategory "other cardiology";

     (m) "Magnetic resonance imaging (MRI)," except subcategory "other MRI";

     (n) "Cast room," except subcategory "other cast room";

     (o) "Recovery room," except subcategory "other recovery room";

     (p) "Labor room/delivery," except for subcategories "circumcision" and "other labor room/delivery";

     (q) "EKG/ECG (electrocardiogram)," except subcategory "other EKG/ECG";

     (r) "EEG (electroencephalogram)," except subcategory "other EEG";

     (s) "Gastrointestinal services," except subcategory "other gastroenteritises";

     (t) "Treatment or observation room," except subcategory "other treatment room";

     (u) "Lithotripsy," except subcategory "other lithotripsy"; and

     (v) "Organ acquisition," except for subcategories "unknown donor" and "other organ."

     (2) Except for certain services, such as inpatient hospice services covered by MAA pursuant to other rules, the department shall cover the following revenue code categories and/or subcategories for inpatient hospitalizations only:

     (a) "Room and board - private, medical, or general," except subcategory "hospice";

     (b) "Semi-private room and board" (two to four beds), except subcategory "hospice";

     (c) "Nursery for newborns and premature babies";

     (d) "Intensive care," except subcategory "post-ICU";

     (e) "Coronary care," except subcategory "post-CCU";

     (f) "Laboratory," except subcategory "renal patient (home)";

     (g) "Laboratory pathological";

     (h) "Radiology," both "diagnostic" and "therapeutic";

     (i) "Nuclear medicine";

     (j) "Physical therapy," "occupational therapy," and "speech-language therapy";

     (k) "CT (computed tomographic) scans";

     (l) "Operating room services," subcategories "organ transplant other than kidney" and "kidney transplant only";

     (m) "Clinic," subcategory "chronic pain center" only;

     (n) "Ambulance," subcategory "neonatal ambulance services (support crews)" only;

     (o) "Other donor bank" category, except that subcategories "peripheral blood stem cell harvesting" and "reinfusion" are limited only to facilities approved by the medical assistance administration (MAA).

     In addition to specifically excluded subcategories, the subcategory "other" in each category shall not be covered.

     (3) Except for certain services, such as inpatient hospice services covered by MAA pursuant to other rules, the department shall cover the following revenue code categories for outpatient hospital services only:

     (a) "Ambulatory surgical care";

     (b) "Outpatient services";

     (c) Subcategories "general classification" and "dental clinic," under "clinic";

     (d) Subcategory "rural health clinic," under "free-standing clinic";

     (e) "Drugs requiring specific identification," except covered only for certified kidney centers;

     (f) "Hospice services";

     (g) "Respite care";

     (h) "Inpatient renal dialysis";

     (i) "Hemodialysis - outpatient or home";

     (j) "Peritoneal dialysis - outpatient or home";

     (k) "Continuous ambulatory peritoneal dialysis - outpatient or home";

     (l) "Continuous cycling peritoneal dialysis - outpatient or home";

     (m) "Miscellaneous dialysis";

     (n) Subcategories "education/training" and "weight loss," under the "other therapeutic services" category, except limited to facilities approved by MAA.

     In addition to specifically excluded subcategories, the subcategory "other" in each category shall not be covered.

     (4) The department shall cover the following revenue code categories and/or subcategories subject to the following specific limitations:

     (a) The "private (deluxe)" and "room and board - ward" categories shall be reimbursed at the semi-private hospital room rates.

     (b) All inpatient psychiatric services shall be subject to the policies and procedures of the mental health division, and reimbursed only to department-approved psychiatric facilities.      See chapter 246-318 WAC.      Inpatient psychiatric revenue codes include, but are not limited to:

     (i) The subcategory "psychiatric" under all "room and board" categories;

     (ii) The subcategory "psychiatric" under the "intensive care" category;

     (iii) The "psychiatric/psychological treatments" category; and

     (iv) The "psychiatric/psychological services" category.

     (c) The department shall reimburse the subcategory "detoxification" under all room and board categories only to detoxification facilities approved by the division of alcohol and substance abuse.

     (d) The subcategory "rehabilitation" under all "room and board" categories shall be reimbursed only to MAA-approved rehabilitation facilities.

     (e) Only the subcategories "chemical-using pregnant women" and "administrative days" shall be covered in the "other room and board" category.

     (f) Subcategory "nonprescription drugs" under the category "pharmacy" shall be covered for inpatient hospitalizations only.      See WAC 388-550-1400 (1)(a)(ii).      Certain exemptions apply for pregnant women as described in WAC ((388-86-024 (2)(c))) 388-530-1150 (1)(d)(ii).      For coverage of nonprescription drugs, see WAC 388-530-110 and 388-530-1150.

     (g) The subcategories "renal patient (home)" and "nonroutine dialysis" under category "laboratory" shall be reimbursed in the outpatient setting only to Medicare-certified kidney centers.

     (h) Subcategory "chronic pain center" under the "clinic" category shall be reimbursed only to MAA-approved chronic pain treatment facilities.

     (i) Only the subcategory "neonatal ambulance services (support crews)" under the "ambulance" category shall be covered, and only for inpatient hospitalizations.

     (j) The category "drugs requiring specific identification" shall be reimbursed only for outpatients and only to Medicare-approved kidney centers.

     (k) Subcategories "education/training" and "weight loss," under the "other therapeutic service" category, shall be reimbursed only to MAA-approved facilities.

[Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020.      98-01-124, § 388-550-1400, filed 12/18/97, effective 1/18/98.]

(1) Providers of hospital-related services to clients not enrolled with the department's managed care carriers shall obtain prior approval from the medical assistance administration (MAA) for hospital services requiring prior approval.      For inpatient psychiatric admissions and inpatient treatment for alcohol and other substance abuse, see chapter 246-318 and 246-326 WAC respectively.

     (2) The department shall require that for medical care clients not enrolled with the department's managed care carriers, providers receive prior approval from the department for the following hospital-related services:

     (a) All nonemergent admissions to or planned inpatient hospital surgeries in nonparticipating hospitals in selective contracting areas;

     (b) Inpatient detoxification, medical stabilization, and drug treatment for a pregnant Medicaid client as described under WAC 388-550-1100(3);

     (c) Cataract surgery that does not meet requirements in WAC ((388-86-030)) 388-544-0550;

     (d) The following surgical procedures, regardless of the diagnosis or place of service:

     (i) Hysterectomies for clients forty-four years and younger;

     (ii) Reduction mammoplasty; and

     (iii) Surgical bladder repair.

     (e) All physical medicine and rehabilitation (PM&R) inpatient hospital stays, even when provided by MAA-approved PM&R contract facilities (see WAC 388-550-2300);

     (f) All outpatient magnetic resonance imaging and magnetic resonance angiography procedures;

     (g) All nonemergent inpatient hospital transfers (see WAC 388-550-3600);

     (h) All out-of-state non-emergent hospital stays;

     (i) Hospital-related services as described in WAC 388-550-1800 when not provided in an MAA-approved facility; and

     (j) Services in excess of the department's established limits.

     (3) The department shall inform providers which diagnosis codes from the International Classification of Diseases, 9th Revision, Clinical Modification and procedure codes from physicians' current procedural terminology require prior authorization for nonemergent hospital admissions.

     (4) When a client's hospitalization exceeds the number of days allowed by WAC 388-550-4300(2):

     (a) The hospital shall, within sixty days after discharge, submit to MAA a request for authorization of the extra days with adequate medical justification, to include at a minimum the following:

     (i) History and physical examination;

     (ii) Social history;

     (iii) Progress notes and doctor's orders for the entire length of stay;

     (iv) Treatment plan/critical pathway; and

     (v) Discharge summary.

     (b) The department shall approve or deny a length of stay extension request within fifteen working days of receiving the request.

     (5) The department shall require prior approval for out-of-state hospital admissions of clients not enrolled with department's managed care carriers, except for emergent hospitalizations.      The department shall inform providers which codes from the current revision of ICD-9CM are designated as emergent diagnosis codes.      The nature of the client's emergent medical condition must be fully documented in the client's hospital's records.

     (6) The department shall not reimburse ambulance providers for ambulance transports in cases involving hospital transfers without prior authorization by the department.

     (7) The department shall require that providers receive prior approval from the department for medical transportation to out-of-state treatment programs or services authorized by the department for clients not enrolled with the department's managed care carriers.

[Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020.      98-01-124, § 388-550-1700, filed 12/18/97, effective 1/18/98.]

(1) The department shall measure the effectiveness of transplant centers of excellence (COE) using the performance criteria in this section.      Unless otherwise waived by the department, the department shall apply these criteria to a facility during both initial and periodic evaluations for designation as a transplant COE.      The COE performance criteria shall include, but not be limited to:

     (a) Meeting annual volume requirements for the specific transplant procedures for which approved;

     (b) Patient survival rates; and

     (c) Relative cost per case.

     (2) A transplant COE shall meet or exceed annually the following applicable volume criteria for the particular transplant procedures performed at the facility, except for cornea transplants which do not have established minimum volume requirements.      Annual volume requirements for transplant centers of excellence include:

     (a) Twelve or more heart transplants;

     (b) Ten or more lung transplants;

     (c) Ten or more heart-lung transplants;

     (d) Twelve or more liver transplants;

     (e) Twenty-five or more kidney transplants;

     (f) Eighteen or more pancreas transplants;

     (g) Eighteen or more kidney-pancreas transplants;

     (h) Ten or more bone marrow transplants; and

     (i) Ten or more peripheral stem cell (PSC) transplants.

     Dual-organ procedures may be counted once under each organ and the combined procedure.

     (3) A transplant facility within the state that fails to meet the volume requirements in subsection (1) of this section may submit a written request to the department for conditional approval as a transplant center of excellence.      The department shall consider the minimum volume requirement met when the requestor submits an approved certificate of need for transplant services from the state department of health.

     (4) An in-state facility granted conditional approval by the department as a transplant center of excellence shall meet the department's criteria, as established in this chapter, within one year of the conditional approval.      The department shall automatically revoke such conditional approval for any facility which fails to meet the department's published criteria within the allotted one year period, unless:

     (a) The facility submits a written request for extension of the conditional approval thirty calendar days prior to the expiration date; and

     (b) Such request is granted by the department.

     (5) A transplant center of excellence shall meet Medicare's survival rate requirements for the transplant procedure(s) performed at the facility.

     (6) A transplant center of excellence shall submit to the department annually, at the same time the hospital submits a copy of its Medicare Cost Report (HCFA 2552 report) documentation showing:

     (a) The numbers of transplants performed at the facility during its preceding fiscal year, by type of procedure; and

     (b) Survival rates data for procedures performed over the preceding three years as reported on the United Network of Organ Sharing report form.

     (7)(a) Transplant facilities shall submit to the department, within sixty days of the date of the facility's approval as a center of excellence, a complete set of the comprehensive patient selection criteria and treatment protocols used by the facility for each transplant procedure it has been approved to perform.

     (b) The facility shall submit to the department updates to said documents annually thereafter, or whenever the facility makes a change to the criteria and/or protocols.

     (c) If no changes occurred during a reporting period the facility shall so notify the department to this effect.

     (8) The department shall evaluate compliance with the provisions of WAC 388-550-2100 (2)(d) and (e) based on the protocols and criteria submitted to the department by transplant centers of excellence in accordance with subsection (7) of this section.      The department shall terminate a facility's designation as a transplant center of excellence if a review or audit finds that facility in noncompliance with:

     (a) Its protocols and criteria in evaluating and selecting candidates for transplantation; and

     (b) Distributing donated organs in a fair and equitable manner that promotes an optimal or successful patient outcome.

     (9)(a) The department shall provide transplant centers of excellence it finds in noncompliance with subsection (8) of this section sixty days within which such centers may submit a plan to correct a breach of compliance;

     (b) The department shall not allow the sixty-day option as stated in (a) of this subsection for a breach that constitutes a danger to the health and safety of clients as stated in WAC ((388-87-005 (3)(d))) 388-502-0030;

     (c) Within six months of submitting a plan to correct a breach of compliance, a center shall report to the department showing:

     (i) The breach of compliance has been corrected; or

     (ii) Measurable and significant improvement toward correcting such breach of compliance.

     (10) The department shall periodically review the list of approved transplant centers of excellence.      The department may limit the number of facilities it designates as transplant centers of excellence or contracts with to provide services to medical care clients if, in the department's opinion, doing so would promote better client outcomes and cost efficiencies.

     (11) The department shall reimburse department-approved centers of excellence for covered transplant procedures using any of the methods identified in chapter 388-550 WAC.

[Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020.      98-01-124, § 388-550-2200, filed 12/18/97, effective 1/18/98.]

(1) The department shall reimburse only emergency care for an eligible Medicaid client who goes to another state, except specified border cities, specifically for the purpose of obtaining medical care that is available in the state of Washington.      See WAC 388-501-0175 for a list of border cities.

     (2) The department shall authorize and provide comparable medical care services to a Medicaid client who is temporarily outside the state to the same extent that such medical care services are furnished to an eligible Medicaid client in the state, subject to the exceptions and limitations in this section.

     (3) The department shall not authorize payment for out-of-state medical care furnished to state-funded clients (medically indigent/medical care services), but may authorize medical services in designated bordering cities.

     (4) The department shall cover hospital care provided to Medicaid clients in areas of Canada as described in WAC 388-501-0180 (((1)(b))).

     (5) The department shall review all cases involving out-of-state medical care to determine whether the services are within the scope of the medical assistance program.

     (6)(a) If the client can claim deductible or coinsurance portions of Medicare, the provider shall submit the claim to the intermediary or carrier in the provider's own state on the appropriate Medicare billing form.

     (b) If the state of Washington is checked on the form as the party responsible for medical bills, the intermediary or carrier may bill on behalf of the provider or may return the claim to the provider for submission to the state of Washington.

     (7) For reimbursement for out-of-state inpatient hospital services, see WAC 388-550-4000.

     (8) The department shall reimburse out-of-state outpatient hospital services billed under the physician's current procedural terminology codes at an amount that is the lower of:

     (a) The billed amount; or

     (b) The rate paid by the Washington state Title XIX Medicaid program.

     (9) Out-of-state providers shall present final charges to MAA within three hundred sixty-five days of the date of service.      In no case shall the state of Washington be liable for payment of charges received beyond one year from the date services were rendered.

[Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020.      98-01-124, § 388-550-6700, filed 12/18/97, effective 1/18/98.]

(1) To provide services other than at FQHCs, independent interpreters and/or interpreter agencies are considered eligible providers when they:

     (a) Are enrolled with MAA to provide interpreter services;

     (b) Meet the criteria in WAC ((388-87-007, Medical provider agreement, and WAC 388-87-010, Conditions of payment--General)) 388-502-0020 and 388-502-0100.

     (2) To enroll as an independent interpreter for MAA clients, interpreters shall submit the following to the department:

     (a) Proof of certification which may be either:

     (i) Number and date of medical certificate from LIST; or

     (ii) A copy of a RID or NAD certificate for certified sign language interpreters.

     (b) A Social Security Number, if the interpreter has one;

     (c) A completed interpreter services core provider agreement;

     (d) A signed confidentiality pledge;

     (e) A completed provider information form; and

     (f) Verification of errors and omissions liability insurance at or over one hundred thousand dollars per occurrence.

     (3) To enroll with MAA as an interpreter agency, the agency shall submit to the department:

     (a) A completed interpreter services core provider agreement;

     (b) Verification of errors and omissions liability insurance at or over one million dollars per occurrence;

     (c) A completed provider information form; and

     (d) A list of interpreters employed/contracted to provide services to MAA clients, including the following information for each interpreter:

     (i) A signed confidentiality pledge; and

     (ii) Number and date of medical certificate from LIST; or

     (iii) A copy of a current RID or NAD certificate for certified sign language interpreters or written description of evaluation process for qualified interpreter status.

     (4) To qualify as an eligible provider, an interpreter agency shall have the capacity to provide interpreter services in:

     (a) American Sign Language; or

     (b) At least three spoken languages; or

     (c) Fewer than three spoken languages if the languages provided are reflective of a majority of the LEP clients residing within the county(ies) served by the agency.      DSHS reports will be used to identify the languages needed in the demographic area.

[Statutory Authority: RCW 74.04.050, 74.08.090, 74.04.025, 45 CFR Sec. 80.1 and 80.03; 45 CFR Sec. 605.52; 28 CFR, part 35.      98-15-054, § 388-555-1150, filed 7/10/98, effective 7/10/98.]

(1) An interpreter or interpreter agency shall not determine the need for interpreter services, nor shall the interpreter market interpreter services to MAA clients. See WAC 388-555-1250, Coordination of services.

     (2) An interpreter or interpreter agency shall not require a client to obtain interpreter services exclusive of other interpreters or interpreter agencies.

     (3) An interpreter or interpreter agency shall adhere to department policies and procedures regarding confidentiality of client records as stated in WAC ((388-501-0150)) 388-01-030.

     (4) An independent interpreter shall enroll with the department as provided in WAC 388-555-1100 and obtain a current medical assistance provider number.

     (5) An interpreter or interpreter agency must participate in an orientation which will be scheduled and given by MAA within their first year of contracting with the department. The department may terminate contracts with any provider who does not participate in the orientation.

     (6) Interpreter agencies shall assume full legal and financial liability for interpreter services provided by employees and contractors.

[Statutory Authority: RCW 74.04.050, 74.08.090, 74.04.025, 45 CFR Sec. 80.1 and 80.03; 45 CFR Sec. 605.52; 28 CFR, part 35. 98-15-054, § 388-555-1200, filed 7/10/98, effective 7/10/98.]

(1) Organ transplants are limited to the cornea, heart, heart-lung, kidney, kidney-pancreas, liver, pancreas, single lung, and bone marrow.

     (2) The department shall provide treatment, dialysis, equipment, and supplies for acute and chronic nonfunctioning kidneys when the client is in the home, hospital, or kidney center as described under WAC ((388-86-050(12))) 388-540-005.

     (3) Detoxification and medical stabilization are provided to chemically-using pregnant women in a hospital.

     (4) The department shall provide detoxification of acute alcohol or other drug intoxication only in a certified detoxification center or in a general hospital having a detoxification provider agreement with the department.

     (5) The department shall provide outpatient chemical dependency treatment in programs qualified under chapter 275-25 WAC and certified under chapter 275-19 WAC or its successor.

     (6) The department may require a second opinion and/or consultation before the approval of any elective surgical procedure.

     (7) The department designates diagnoses that may require surgical intervention:

     (a) Performed in other than a hospital in-patient setting; and

     (b) Requiring prior approval by the department for a hospital admission.

[00-11-183, recodified as § 388-556-0400, filed 5/24/00, effective 5/24/00.      Statutory Authority: RCW 74.04.050, 74.04.055, 74.04.057 and 74.08.090.      98-18-079, § 388-86-005, filed 9/1/98, effective 9/1/98.      Statutory Authority: RCW 74.08.090.      95-22-039 (Order 3913, #100246), § 388-86-005, filed 10/25/95, effective 10/28/95; 93-17-038 (Order 3620), § 388-86-005, filed 8/11/93, effective 9/11/93; 92-03-084 (Order 3309), § 388-86-005, filed 1/15/92, effective 2/15/92; 90-17-122 (Order 3056), § 388-86-005, filed 8/21/90, effective 9/21/90; 90-12-051 (Order 3009), § 388-86-005, filed 5/31/90, effective 7/1/90; 89-18-033 (Order 2860), § 388-86-005, filed 8/29/89, effective 9/29/89; 89-13-005 (Order 2811), § 388-86-005, filed 6/8/89; 88-06-083 (Order 2600), § 388-86-005, filed 3/2/88.      Statutory Authority: 1987 1st ex.s. c 7.      88-02-034 (Order 2580), § 388-86-005, filed 12/31/87.      Statutory Authority: RCW 74.08.090.      87-12-050 (Order 2495), § 388-86-005, filed 6/1/87; 84-02-052 (Order 2060), § 388-86-005, filed 1/4/84; 83-17-073 (Order 2011), § 388-86-005, filed 8/19/83; 83-01-056 (Order 1923), § 388-86-005, filed 12/15/82; 82-10-062 (Order 1801), § 388-86-005, filed 5/5/82; 82-01-001 (Order 1725), § 388-86-005, filed 12/3/81; 81-16-033 (Order 1685), § 388-86-005, filed 7/29/81; 81-10-015 (Order 1647), § 388-86-005, filed 4/27/81; 80-15-034 (Order 1554), § 388-86-005, filed 10/9/80; 78-06-081 (Order 1299), § 388-86-005, filed 6/1/78; 78-02-024 (Order 1265), § 388-86-005, filed 1/13/78; Order 994, § 388-86-005, filed 12/31/74; Order 970, § 388-86-005, filed 9/13/74; Order 911, § 388-86-005, filed 3/1/74; Order 858, § 388-86-005, filed 9/27/73; Order 781, § 388-86-005, filed 3/16/73; Order 738, § 388-86-005, filed 11/22/72; Order 680, § 388-86-005, filed 5/10/72; Order 630, § 388-86-005, filed 11/24/71; Order 581, § 388-86-005, filed 7/20/71; Order 549, § 388-86-005, filed 3/31/71, effective 5/1/71; Order 453, § 388-86-005, filed 5/20/70, effective 6/20/70; Order 419, § 388-86-005, filed 12/31/69; Order 264 (part); § 388-86-005, filed 11/24/67.]

Reviser's note: The bracketed material preceding the section above was supplied by the code reviser's office.

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