SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Preproposal statement of inquiry was filed as WSR 09-05-055.
Title of Rule and Other Identifying Information: WAC 388-501-0050 Healthcare -- general coverage, 388-501-0070 Healthcare coverage -- Noncovered services, 388-501-0163 Healthcare coverage -- Process for submitting a valid request for authorization, and 388-501-0169 Healthcare coverage -- Limitation extension.
Hearing Location(s): Blake Office Park East, Rose Room, 4500 10th Avenue S.E., Lacey, WA 98503 (one block north of the intersection of Pacific Avenue S.E. and Alhadeff Lane. A map or directions are available at http://www.dshs.wa.gov/msa/rpau/docket.html or by calling (360) 664-6094), on August 4, 2009, at 10:00 a.m.
Date of Intended Adoption: Not sooner than August 5, 2009.
Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504-5850, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail DSHSRPAURulesCoordinator@dshs.wa.gov, fax (360) 664-6185, by 5 p.m. on August 4, 2009.
Assistance for Persons with Disabilities: Contact Jennisha Johnson, DSHS rules consultant, by July 21, 2009, TTY (360) 664-6178 or (360) 664-6094 or by e-mail at email@example.com.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules:
|•||Clarify that providers must be enrolled with the department and meet the requirements of chapter 388-502 WAC to be paid for furnishing healthcare services to clients;|
|•||Clarify when the department pays for healthcare services;|
|•||Clarify that the department does not reimburse clients for healthcare services purchased out-of-pocket;|
|•||Clarify that the department does not pay for the replacement of department-purchased equipment, devices, or supplies which have been sold, lost, broken, destroyed, or stolen as a result of carelessness, negligence, recklessness, or misuse;|
|•||Clarify how a noncovered healthcare service, recommended during an EPSDT exam is evaluated by the department for coverage;|
|•||Correctly alphabetize the list of noncovered items;|
|•||Add discography and upright magnetic resonance imaging to the list of noncovered services;|
|•||Clarify that a client has the right to an administrative hearing, if one is available under state and federal laws.|
|•||Add a new section (WAC 388-501-0163) to clarify the process for submitting a valid request for authorization; and|
|•||Clarify limitation extensions.|
Statutory Authority for Adoption: RCW 74.04.050, 74.08.090, 74.09.530, 74.09.700.
Statute Being Implemented: RCW 74.08.090.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Department of social and health services, governmental.
Name of Agency Personnel Responsible for Drafting: Wendy L. Boedigheimer, P.O. Box 45504, Olympia, WA 98504, (360) 725-1306; Implementation and Enforcement: Gail Kreiger, P.O. Box 45560, Olympia, WA 98504, (360) 725-1681.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The proposed rules do not impose any new costs on small businesses.
A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Gail Kreiger, P.O. Box 45560, Olympia, WA 98504-5560, phone (360) 725-1681, fax (360) 586-9727, e-mail firstname.lastname@example.org.
June 25, 2009
Stephanie E. Schiller
(1) Healthcare service categories listed in WAC 388-501-0060 do not represent a contract for healthcare services.
(2) For the provider to receive payment, the client must be eligible for the covered healthcare service on the date the healthcare service is performed or provided.
(3) Under the department's fee-for-service programs, providers must be enrolled with the department and meet the requirements of chapter 388-502 WAC to be paid for furnishing healthcare services to clients.
(4) The department pays only for ((
medical or dental
services, equipment, or supplies)) the healthcare services
(a) Within the scope of the client's medical program;
(b) Covered - see subsection ((
(5))) (8) of this section;
(d))) Ordered or prescribed by a healthcare provider
meeting)) who meets the requirements of chapter 388-502 WAC;
(d) Medically necessary as defined in WAC 388-500-0005;
(e) Submitted for authorization, when required, in accordance with WAC 388-501-0163;
(f) Approved, when required, in accordance with WAC 388-501-0165;
(g) Furnished by a provider according to ((
requirements of)) chapter 388-502 WAC; and
(h) Billed in accordance with department program rules and the department's current published billing instructions and numbered memoranda.
(4) The department's fee-for-service program pays only
for services furnished by enrolled providers who meet the
requirements of chapter 388-502 WAC.))
(5) The department does not pay for any healthcare
, treatment, equipment, drug, or supply)) requiring
prior authorization from the department, if prior
authorization was not obtained before the healthcare service
(6) The department does not reimburse clients for healthcare services purchased out-of-pocket.
(7) The department does not pay for the replacement of department-purchased equipment, devices, or supplies which have been sold, lost, broken, destroyed, or stolen as a result of carelessness, negligence, recklessness, or misuse unless otherwise allowed in specific program rules.
(8) Covered healthcare services
(a) Covered healthcare services are either:
(i) "Federally mandated" - means the state of Washington is required by federal regulation (42 CFR 440.210 and 220) to cover the healthcare service for medicaid clients; or
(ii) "State-option" - means the state of Washington is not federally mandated to cover the healthcare service but has chosen to do so at its own discretion.
(b) The department may limit the scope, amount, duration, and/or frequency of covered healthcare services. Limitation extensions are authorized according to WAC 388-501-0169.
(7))) (9) Noncovered healthcare services
(a) The department does not pay for any healthcare
, equipment, or supply)):
(i) That federal or state laws or regulations prohibit the department from covering; or
(ii) Listed as noncovered in WAC 388-501-0070 or in any other program rule. The department evaluates a request for a noncovered healthcare service only if an exception to rule is requested according to the provisions in WAC 388-501-0160.
(b) When a noncovered healthcare services is recommended
during the Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) ((
applies, a noncovered)) exam and then
ordered by a provider, the department evaluates the healthcare
service(( , equipment, or supply will be evaluated)) according
to the process in WAC 388-501-0165 to determine if it is
medically necessary, safe, effective, and not experimental
(see WAC 388-534-0100 for EPSDT rules).
[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-501-0050, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090. 01-12-070, § 388-501-0050, filed 6/4/01, effective 7/5/01. Statutory Authority: RCW 74.04.050 and 74.08.090. 00-01-088, § 388-501-0050, filed 12/14/99, effective 1/14/00.]
(2) This section does not apply to healthcare services
under)) as a result of the early and periodic
screening, diagnosis, and treatment (EPSDT) program as
described in chapter 388-534 WAC.
(3) The department does not pay for any ancillary healthcare service(s) provided in association with a noncovered healthcare service.
(4) The following list of noncovered healthcare services is not intended to be exhaustive. Noncovered healthcare services include, but are not limited to:
(a) Any healthcare service specifically excluded by federal or state law;
(b) Acupuncture, Christian Science practice, faith healing, herbal therapy, homeopathy, massage, massage therapy, naturopathy, and sanipractice;
(c) Chiropractic care for adults;
(d) Cosmetic, reconstructive, or plastic surgery, and any
related healthcare services ((
and supplies)), not specifically
allowed under WAC 388-531-0100(4).
(f) Ear or other body piercing;
(f))) (g) Face lifts or other facial cosmetic
(g) Gender reassignment surgery and any surgery related
to transsexualism, gender identity disorders, and body
dysmorphism, and related services, supplies, or procedures,
including construction of internal or external genitalia,
breast augmentation, or mammoplasty;))
Hair transplants, epilation (hair removal), and
(i))) Fertility, infertility or sexual dysfunction testing, and related care, drugs, and/or treatment including but not limited to:
(i) Artificial insemination;
(ii) Donor ovum, sperm, or surrogate womb;
(iii) In vitro fertilization;
(iv) Penile implants;
(v) Reversal of sterilization; and
(vi) Sex therapy.
(j))) (i) Gender reassignment surgery and any surgery
related to trans-sexualism, gender identity disorders, and
body dysmorphism, and related healthcare services or
procedures, including construction of internal or external
genitalia, breast augmentation, or mammoplasty;
(j) Hair transplants, epilation (hair removal), and electrolysis;
(k) Marital counseling;
(k))) (l) Motion analysis, athletic training
evaluation, work hardening condition, high altitude simulation
test, and health and behavior assessment;
(l))) (m) Nonmedical equipment;
(m))) (n) Penile implants;
(n))) (o) Prosthetic testicles;
(o))) (p) Psychiatric sleep therapy;
(p))) (q) Subcutaneous injection filling;
(q))) (r) Tattoo removal;
(r))) (s) Transport of Involuntary Treatment Act (ITA)
clients to or from out-of-state treatment facilities,
including those in bordering cities; (( and))
(s))) (t) Upright magnetic resonance imaging (MRI); and
(u) Vehicle purchase - new or used vehicle.
(5) For a specific list((
ing)) of noncovered healthcare
services in the following service categories, refer to the
(( accompanying)) WAC citation:
(a) Ambulance transportation and nonemergent
transportation as described in ((
WAC 388-546-0250)) chapter 388-546 WAC;
(b) Dental services ((
())for clients twenty(( -one)) years
of age and younger(( ))) as described in chapter 388-535 WAC;
(c) Dental services ((
())for clients twenty-one years of
age and older(( ))) as described in chapter 388-535 WAC;
(d) Durable medical equipment as described in ((
WAC 388-543-1300)) chapter 388-543 WAC;
(e) Hearing care services as described in ((
WAC 388-544-1400)) chapter 388-547 WAC;
(f) Home health services as described in WAC 388-551-2130;
(g) Hospital services as described in WAC 388-550-1600;
(h) Physician-related services as described in WAC 388-531-0150;
(i) Prescription drugs as described in ((
WAC 388-530-1150)) chapter 388-530 WAC; and
(j) Vision care services as described in ((
WAC 388-544-0475)) chapter 388-544 WAC.
(6) A client has a right to request an administrative
when a service is denied as noncovered)), if one is
available under state and federal law. When the department
denies all or part of a request for a noncovered healthcare
service(s) (( or equipment)), the department sends the client
and the provider written notice, within ten business days of
the date the decision is made, that includes:
(a) A statement of the action the department intends to take;
(b) Reference to the specific WAC provision upon which the denial is based;
(c) Sufficient detail to enable the recipient to:
(i) Learn why the department's action was taken; and
(ii) Prepare a response to the department's decision to classify the requested healthcare service as noncovered.
(d) The specific factual basis for the intended action; and
(e) The following information:
The client's)) General administrative hearing
(ii) Instructions on how to request the hearing;
(iii) Acknowledgement that a client may be represented at the hearing by legal counsel or other representative;
Upon the client's request, the name and address of
the nearest legal services office;
(v))) Instructions on how to request an exception to rule
(vi))) (v) Information regarding department-covered
healthcare services, if any, as an alternative to the
requested noncovered healthcare service; and
(vi) Upon the client's request, the name and address of the nearest legal services office.
(7) A client can request an exception to rule (ETR) as described in WAC 388-501-0160.
[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 07-04-036, § 388-501-0070, filed 1/29/07, effective 3/1/07.]
(a) For healthcare services that require prior authorization (PA), a provider (as defined in WAC 388-500-0005) must submit a written, electronic, or telephonic request to the department. To be a valid request for prior authorization, the provider must submit the request and conform to the department's current published program billing instructions, numbered memoranda, and any additional requirements in Washington Administrative Code (WAC) and/or Revised Code of Washington (RCW).
(b) For expedited prior authorization (EPA), a provider must certify that the client's clinical condition meets the appropriate EPA criteria outlined in the department's current published program billing instructions, numbered memoranda, and any additional requirements in WAC and/or RCW. The provider must use the department-assigned EPA number when submitting a claim for payment to the department.
(c) The department requires prior authorization for covered healthcare services when the applicable expedited prior authorization criteria are not met.
(d) Upon request, a provider must submit documentation to the department showing how the client's condition meets the required criteria for PA or EPA.
(2) Department authorization requirements for covered healthcare services are not a denial of service and do not create a right to an administrative hearing.
(3) The department returns invalid requests to the provider and takes no further action unless the request for authorization is resubmitted. The return of an invalid request is not a denial of service and does not create a right to an administrative hearing.
(4) Failure of a provider to request authorization for a healthcare service that requires it or a provider's failure to do so properly is not a denial of service and does not create a right to an administrative hearing.
(5) The department's authorization of healthcare service(s) does not guarantee payment. See WAC 388-501-0050 for other general requirements that must be satisfied before payment can be made for a healthcare service requested and authorized under this section.
(6) The department evaluates a request for an authorization of a healthcare service that exceeds identified limitations, on a case-by-case basis and in accordance with WAC 388-501-0169.
(7) The department may recoup any payment made to a provider if the department later determines the healthcare service was not properly authorized or did not meet EPA criteria. Refer to chapters 388-502 and 388-502A WAC.
(1) No limitation extension of covered healthcare services will be authorized when prohibited by specific program rules.
(2) When ((
an)) a limitation extension is not prohibited
by specific program rules, (( a client or)) the client's
provider may request a limitation extension.
Under fee-for-service (FFS),)) The department
evaluates requests for limitation extensions (( using)) as
(a) For a fee-for-service client, the process described in WAC 388-501-0165.
(b) For a managed care enrollee, the client's managed care organization (MCO) evaluates requests for limitation extensions according to the MCO's prior authorization process.
(4) In addition to subsection (3),)) (c) Both the
department and MCO consider the following in evaluating a
request for a limitation extension:
(a))) (i) The level of improvement the client has shown
to date related to the requested healthcare service and the
reasonably calculated probability of continued improvement if
the requested healthcare service is extended; and
(b))) (ii) The reasonably calculated probability the
client's condition will worsen if the requested healthcare
service is not extended.
[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-501-0169, filed 11/30/06, effective 1/1/07.]