Original Notice.

Preproposal statement of inquiry was filed as WSR 00-18-110.

Title of Rule: WAC 388-502-0160 Billing the client.

Purpose: To clarify requirements under which the MAA allows a contracted provider to bill a medical assistance client directly.

Statutory Authority for Adoption: RCW 74.08.090.

Statute Being Implemented: RCW 74.08.090.

Summary: The proposed amendment clarifies some requirements that were adopted in July and effective in August 2000.

Reasons Supporting Proposal: To clarify certain provisions of the rule.

Name of Agency Personnel Responsible for Drafting: Leslie Saeger, P.O. Box 45533, Olympia, WA 98504, (360) 725-1347; Implementation and Enforcement: Alan Himsl, P.O. Box 45533, Olympia, WA 98504, (360) 725-1347.

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

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

Explanation of Rule, its Purpose, and Anticipated Effects: The purpose of this amendment is to clarify certain provisions of a rule that became effective in August 2000. The department is not intending to change the intent of the current rule, only to add clarifying information.

Proposal does not change existing rules. Clarifies requirements in WAC 388-502-0160.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rule and determined that this amendment does not impose new costs on businesses affected by it.

RCW 34.05.328 does not apply to this rule adoption. According to RCW 34.05.328 (5)(iv), this rule action is exempt because it clarifies language without changing the effect of the rule.

Hearing Location: Blake Office Building, 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on January 9, 2001, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Kelly Cooper by January 2, 2001, phone (360) 902-7540, TTY (360) 902-8324, e-mail coopekd@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, Kelly Cooper, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 902-8292, by January 9, 2001.

Date of Intended Adoption: Not sooner than January 9, 2001.

November 28, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

     (2) The provider is responsible ((to verify)) for verifying whether the client has medical coverage for the date of service and to check the limitations of the client's medical program.

     (3) A provider may bill a client only if one of the following situations apply:

     (a) The client is enrolled in ((a)) medical assistance managed care ((plan)) and the client and provider comply with the requirements in WAC 388-538-095;

     (b) The client is not enrolled in ((a program other than)) medical assistance managed care, and the client and provider sign an agreement regarding payment for the service.      ((It)) The agreement must be translated or interpreted into the client's primary language and signed before the service is rendered.      The provider must give the client a copy and maintain the original in the client's file for department review upon request.      The agreement must include each of the following elements to be valid:

     (i) The specific service to be provided;

     (ii) A statement that the service is not covered by MAA;

     (iii) A statement that the client chooses to receive and pay for the specific service; and

     (iv) The client is not obligated to pay for the service if it is later found that the service was covered by MAA at the time it was provided, even if MAA did not pay the provider for the service because the provider did not satisfy MAA's billing requirements;

     (c) The client or the client's legal guardian was reimbursed for the service directly by a third party (see WAC 388-501-0200);

     (d) The client refuses to complete and sign insurance forms, billing documents, or other forms necessary for the provider to bill insurance for the service. (Medical assistance is not insurance);

     (e) The provider has documentation that the client represented himself/herself as a private pay patient ((and not receiving medical assistance)) when the patient was already eligible for and receiving benefits under a DSHS medical program.      The documentation (declaration of self-pay) must be signed and dated by the ((client)) patient or the ((client's)) patient's representative.      The provider must give a copy to the ((client)) patient and maintain the original documentation in the patient's file for department review upon request.      In this case, the provider may bill the client without fulfilling the requirements in subsection (3)(b) of this section regarding the agreement to pay. However, if the patient later becomes eligible for ((the service due to delayed or retroactive eligibility)) a medical assistance program that covers the service, and the patient's (client's) eligibility is effective for the date of service, the provider must comply with subsection (4) of this section. If the patient becomes eligible for a medical assistance program, but the service received is not covered by the program, the patient (client) is responsible for payment;

     (((e) The client refuses to complete and sign insurance forms, billing documents, or other forms necessary for the provider to bill insurance for the service.      Medical Assistance is not insurance;)) or

     (f) The bill counts toward a spenddown liability, emergency medical expense requirement, deductible, or copayment required by MAA.

     (4) If a client becomes eligible for a covered service that has already been provided ((due to)) because the client:

     (a) ((Delayed eligibility)) Applied to the department for medical services later in the same month the service was provided (and is made eligible from the first day of the month), the provider must:

     (i) Not bill, demand, collect, or accept payment from the client or anyone on the client's behalf for the service; and

     (ii) Promptly refund the total payment received from the client or anyone on the client's behalf, and then bill MAA for the service((.));

     (b) Receives a delayed certification as defined in WAC 388-500-0050, the provider:

     (i) Not bill, demand, collect, or accept payment from the client or anyone on the client's behalf for the service; and

     (ii) Promptly refund the total payment received from the client or anyone on the client's behalf, and then bill MAA for the service; or

     (c) Receives a retroactive ((eligibility)) certification as defined in WAC 388-500-0050, the provider:

     (i) Must not bill, demand, collect, or accept payment from the client or anyone on the client's behalf for any unpaid charges for the service; and

     (ii) May refund any payment received from the client or anyone on the client's behalf, and ((then)) after refunding the payment, the provider may bill MAA for the service.

     (5) Hospitals may not bill, demand, collect, or accept payment from a medically indigent, GA-U, or ADATSA client, or anyone on the client's behalf, for inpatient or outpatient hospital services during a period of eligibility, except for spenddown.

     (6) A provider may not bill, demand, collect, or accept payment from a client, anyone on the client's behalf, or MAA for copying or otherwise transferring health care information, as that term is defined in chapter 70.02 RCW, to another health care provider.      This includes, but is not limited to:

     (a) Medical charts;

     (b) Radiological or imaging films; and

     (c) Laboratory or other diagnostic test results.

[Statutory Authority: RCW 74.08.090 and 74.09.520.      00-14-069, § 388-502-0160, filed 7/5/00, effective 8/5/00.]

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