WSR 01-01-012



(Medical Assistance Administration)

[ Filed December 6, 2000, 3:27 p.m. ]

Date of Adoption: December 6, 2000.

Purpose: The department is establishing a new chapter for rules pertaining to physician-related services, and in order to avoid duplication, is repealing existing rules on the same subject. The new rules meet the clear-writing mandates in the Governor's Executive Order 97-02, and ensure that current policy and practice are reflected in rule, new chapter 388-531 WAC.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-86-011, 388-86-055, 388-86-095, 388-86-110, 388-86-0961, 388-87-075, and 388-87-095.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.520.

Adopted under notice filed as WSR 00-12-080 on June 6, 2000.

Changes Other than Editing from Proposed to Adopted Version: (Deleted words shown as strikeout and added words shown as underline.)

WAC 388-531-0050:

"Allowed charges" means the maximum amount reimbursed for any procedure that is allowed by MAA.

"Covered service" means a service that is within the scope of the eligible client's medical care program, and listed in specific fee-for-service billing instructions. subject to the limitations in this chapter and other published WAC.

"Experimental" means... (2) Has been approved by the FDA or other requisite government body, if such approval is required.

"Fee-for-service" means the general payment method MAA uses to reimburse providers for covered medical services provided to medical assistance clients for whom when those services are not covered under MAA's healthy options program or children's health insurance (CHIP) programs.

"Investigational" means a term to describe a procedure, or course of treatment, which lacks sufficient scientific evidence of benefit for a particular condition. A service is not "investigational" if the service:...

(2) Is supported by a preponderance an overall balance of objective scientific evidence, in which the potential risks and potential benefits are examined...

WAC 388-531-0100:

(2) MAA evaluates a request for any service that is listed as noncovered in WAC 388-531-0150 under the provisions of WAC 388-501-0165 which relate to noncovered services.

(5) MAA covers the following physician-related services, subject to the conditions in subsection (1), and (2) (3), and (4) of this section:...

(5)(l) Ophthalmology care Vision-related services per chapter 388-544 WAC;

WAC 388-531-0150:

(1)(i): Orthoptic eye training therapy; Vision-related services listed as non-covered in chapter 388-544 WAC;

WAC 388-531-0250 (1)(k):

(iv) Optometry, for vision-related optometric services; or

(v) Podiatry, for podiatric services.

WAC 388-531-0450 (2)(a): The client is critically ill and the physician is engaged in work directly related to the individual clients care, whether that time is spent at the immediate beside bedside, or elsewhere on the floor;

WAC 388-531-0550:

(2) In making The determination of whether a service is experimental and/or investigational and therefore, not a covered service, MAA considers the following: is subject to a case-by-case review under the provisions of WAC 388-501-0165 which relate to medical necessity. MAA also considers the following:

(2)(b) Whether evidence indicates the service or treatment is more likely than not to be as beneficial as existing conventional treatment alternatives for the treatment of the condition in question;

(2)(c) Any relevant, specific aspects of the condition; (the subsections following this, ((d), (e), (f), (g), (h), and (i)) are renumbered, respectively, as (c), (d), (e), (f), (g), and (h).)

(2)(d) (c) Whether the service or treatment is generally used or generally accepted for treatment of for the condition in the state of Washington United States.

(3) MAA applies consistently across clients with the same medical condition and health status, the criteria to determine whether a service is experimental. A service that is not experimental for one client with a particular medical condition is not determined to be experimental for another enrollee with the same medical condition and similar health status. A service that is experimental for one client with a particular medical condition is not necessarily experimental for another, and subsequent individual determinations must consider any new or additional evidence not considered in prior determinations.

(4) MAA does not determine a service or treatment to be experimental or investigational solely because it is under clinical investigation, when there is sufficient evidence in peer-reviewed medical literature to draw conclusions, and the evidence indicates the service or treatment will probably be of greater overall benefit to the client in question and to others similarly situated, than another generally available service.

WAC 388-531-0750:

Inpatient hospital inpatient physician-related services.

WAC 388-531-0800:

(1) MAA reimburses a providers for laboratory services only when they are:

(a) The provider is Are certified according to Title XVII of the Social Security Act (Medicare), if required; and

(a) The provider has Have a clinical laboratory improvement amendment (CLIA) certificate and identification number.

(11) An independent laboratory must bill MAA directly. MAA does not reimburse a medical practitioner for services referred to or performed by an independent laboratory.

WAC 388-531-0950:

(1)(a) Two calls per month for routine medical conditions for a client residing in a nursing facility;

(1)(b) One call per noninstitutionalized client, per day, per for an individual physician....

(5)(b) The injectable drug used is from office stock and purchased by the provider from...

(9)(a) MAA does not pay separately reimburse for the administration of intra-arterial and intravenous therapeutic or diagnostic injections provided in conjunction with intravenous infusion therapy services. MAA does pay reimburse separately for the administration of these injections when they are provided on the same day as an E&M service. MAA does not pay separately an administration fee for injectables when both E&M and infusion therapy services are provided on the same day. MAA reimburses separately for the drug(s).

(9)(b) MAA does not reimburse pay separately for subcutaneous or intramuscular administration of antibiotic injections provided on the same day as an E&M service. If the injection is the only service provided, MAA covere the injection service pays an administration fee. ...

(9)(d) The provider must submit a manufacturer's invoice and to document the name, strength, and dosage on the claim form when billing MAA for the following drugs:

(i) Classified drugs that cost where the billed charge is over one thousand, one hundred dollars; and

(i) Unclassified drugs that cost where the billed charge is over one hundred dollars; and This does not apply to unclassified antineoplastic drugs.

(i) Unclassified antineoplastic drugs that cost over five hundred dollars.

(10)(b) When a single client is expected to use all the doses in a multiple dose vial, the provider must may bill MAA the total number of doses in a multiple dose vial the vial at the time the first dose from the vial is used. (c) When remaining doses of a the multiple dose vial are injected at subsequent times, MAA reimburses the injection service (administration fee) only.

(c) When a multiple dose vial is used for more than one client, the provider must bill the total number of doses provided to each client out of the multiple dose vial.

(d) MAA covers both the injection and the antigen, the antigen preparation, and an administration fee.

(11) MAA reimburses for chemotherapy drugs:

(11)(a) MAA reimburses for chemotherapy drugs Administered in the physician's office only when:...

(11)(b) MAA establishes a At established maximum allowable fees based on its the Medicare pricing of the estimated acquisition cost (EAC) or maximum allowable cost (MAC), when generics are available;.

(11)(c) For unclassified antineoplastic drugs, the provider must submit the following information on the claim form:

(i) The name of the drug used;

(i) The dosage and strength used; and

(i) The national drug code (NCD).

(12) Notwithstanding the provisions of this section, MAA reserves the option of determining drug pricing for any particular drug based on the best evidence available to MAA, or other good and sufficient reasons (e.g., fairness/equity, budget), regarding the actual cost, after discounts and promotions, paid to typical providers nationally or in Washington state.

(13) MAA may request an invoice as necessary.

WAC 388-531-1000:

Opthalmological Ophthalmic and vision-related physician-related services.

(1) MAA covers opthalmological services furnished by a provider as listed in WAC 388-531-0250, and subject to the limitations in this section and other published WAC.

(1) MAA requires expedited prior authorization for strabismus surgery for clinet eighteen years of age and older.

(1) MAA does not cover any of the following:

(a) Orthoptics and visual training therapy;

(b) Two pairs of eyeglasses;

(c) E&M services billed in combination with eye exam procedure codes;

(d) Radial Keratotomy or other surgery for refractive purposes;

(e) Refractive prescriptions over two years old; of

(f) Group screening for eyeglasses (except for EPSDT).

Refer to chapter 388-544 WAC for ophthalmic and vision-related services.

WAC 388-531-1050:

Osteopathic manipulative therapy treatment.

WAC 388-531-1100:

(1) MAA covers medical services provided to Medicaid eligible clients who are temporarily located outside the state, subject to the provisions of this chapter and WAC 388-501-0180.

WAC 388-531-1400:

(5) MAA reimburses only one psychiatric diagnostic interview examination in a calendar year unless a significant change in the client's circumstances renders such a an additional evaluation medically necessary.

WAC 388-531-1550:

(11) MAA reimburses hysterectomy without prior authorization in either of the following circumstances: (a) the client has been diagnosed with cancer(s) of the female reproductive organs; and/or (b) the client is forty-six years of age or older.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 38, Amended 0, Repealed 7.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 38, Amended 0, Repealed 7.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 38, Amended 0, Repealed 7. Effective Date of Rule: Thirty-one days after filing.

December 6, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

Reviser's note: The material contained in this filing exceeded the page-count limitations of WAC 1-21-040 for appearance in this issue of the Register. It will appear in the 01-03 issue of the Register.

Washington State Code Reviser's Office