SOCIAL AND HEALTH SERVICES
(Medicaid Purchasing Administration)
Effective Date of Rule: Thirty-one days after filing.
Purpose: Correcting errant WAC cross references and correcting the name of the medicaid purchasing administration.
Citation of Existing Rules Affected by this Order: Amending WAC 388-502-0100 General conditions of payment, 388-502A-0200 Definitions, 388-530-3200 The department's authorization process, 388-533-0400 Maternity care and newborn delivery, 388-544-0600 Vision care -- Payment methodology, and 388-556-0100 Chemical dependency treatment services.
Statutory Authority for Adoption: RCW 74.08.090.
Adopted under notice filed as WSR 11-06-067 on March 2, 2011.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 6, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 6, Repealed 0.
Date Adopted: April 28, 2011.
Katherine I. Vasquez
(a) The service is within the scope of care of the client's medical assistance program;
(b) The service is medically or dentally necessary;
(c) The service is properly authorized;
(d) The provider bills within the time frame set in WAC 388-502-0150;
(e) The provider bills according to department rules and billing instructions; and
(f) The provider follows third-party payment procedures.
(2) The department is the payer of last resort, unless the other payer is:
(a) An Indian health service;
(b) A crime victims program through the department of labor and industries; or
(c) A school district for health services provided under the Individuals with Disabilities Education Act.
(3) The department does not reimburse providers for medical services identified by the department as client financial obligations, and deducts from the payment the costs of those services identified as client financial obligations. Client financial obligations include, but are not limited to, the following:
(a) Copayments (co-pays) (unless the criteria in chapter 388-517 WAC or WAC 388-501-0200 are met);
(b) Deductibles (unless the criteria in chapter 388-517 WAC or WAC 388-501-0200 are met);
(c) Emergency medical expense requirements (EMER) (see WAC 388-550-1050 and 388-865-0217); and
(d) Spenddown (see WAC 388-519-0110).
(4) The provider must accept medicare assignment for claims involving clients eligible for both medicare and medical assistance before the department makes any payment.
(5) The provider is responsible for verifying whether a client has medical assistance coverage for the dates of service.
(6) The department may reimburse a provider for services provided to a person if it is later determined that the person was ineligible for the service at the time it was provided if:
(a) The department considered the person eligible at the time of service;
(b) The service was not otherwise paid for; and
(c) The provider submits a request for payment to the department.
(7) The department does not pay on a fee-for-service basis for a service for a client who is enrolled in a managed care plan when the service is included in the plan's contract with the department.
(8) Information about medical care for jail inmates is found in RCW 70.48.130.
(9) The department pays for medically necessary services on the basis of usual and customary charges or the maximum allowable fee established by the department, whichever is lower.
[Statutory Authority: RCW 74.08.090. 10-19-057, § 388-502-0100, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 71.05.560, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. 06-13-042, § 388-502-0100, filed 6/15/06, effective 7/16/06. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.530. 00-15-050, § 388-502-0100, filed 7/17/00, effective 8/17/00.]
"Audit period" -- The time period the department selects to review a provider's records. This time period is indicated in the audit report.
"Chargemaster" -- A list of all goods and services and the prices the provider charges for each of those goods and services.
"Extrapolation" -- The methodology of estimating an unknown value by projecting, with a calculated precision (i.e., margin of error), the results of an audited sample to the universe from which the sample was drawn.
"Medical assistance" -- For purposes of this chapter, the common phrase used to describe all medical programs available through the department.
"Overpayment" -- Any payment or benefit to a client or to a vendor in excess of what is entitled by law, rule or contract, including amounts in dispute, as defined in RCW 43.20B.010.
"Record" -- Documentation maintained by a health services
provider to show the details of the providing of services or
products to a medical assistance client. See also WAC 388-502-0020, ((
general provider)) healthcare record
"Sample" -- A selection of claims reviewed under a defined audit process.
"Universe" -- A defined population of claims submitted by a provider for payment during a specific time period.
"Usual and customary charge" -- The rate providers must bill the department for a certain service or equipment. This rate may not exceed:
(1) The established charge billed to the general public for the same services; or
(2) If the general public is not served, the established rate normally offered to other payers for the same services.
[Statutory Authority: RCW 74.09.200 and 74.08.090. 07-10-022, § 388-502A-0200, filed 4/23/07, effective 6/1/07.]
(a) Use of expedited authorization codes as published in the department's prescription drug program billing instructions and numbered memoranda;
(b) Use of specified values in national council of prescription drug programs (NCPDP) claim fields;
(c) Use of diagnosis codes; and
(d) Evidence of previous therapy within the department's claim history.
(2) When the automated requirements in subsection (1) of this section do not apply or cannot be satisfied, the pharmacy provider must request authorization from the department before dispensing. The pharmacy provider must:
(a) Ensure the request states the medical diagnosis and includes medical justification for the drug, device, drug-related supply, or circumstance as listed in WAC 388-530-3000(4); and
(b) Keep documentation on file of the prescriber's
medical justification that is communicated to the pharmacy by
the prescriber at the time the prescription is filled. The
records must be retained for the period specified in WAC
388-502-0020 (1)(c))) 388-502-0020(5).
(3) When the department receives the request for authorization:
(a) The department acknowledges receipt:
(i) Within twenty-four hours if the request is received during normal state business hours; or
(ii) Within twenty-four hours of opening for business on the next business day if received outside of normal state business hours.
(b) The department reviews all evidence submitted and takes one of the following actions within fifteen business days:
(i) Approves the request;
(ii) Denies the request if the requested service is not medically necessary; or
(iii) Requests the prescriber submit additional justifying information.
(A) The prescriber must submit the additional information within ten days of the department's request.
(B) The department approves or denies the request within five business days of the receipt of the additional information.
(C) If the prescriber fails to provide the additional information within ten days, the department will deny the requested service. The department sends a copy of the request to the client at the time of denial.
(4) The department's authorization may be based on, but not limited to:
(a) Requirements under this chapter and WAC 388-501-0165;
(b) Client safety;
(c) Appropriateness of drug therapy;
(d) Quantity and duration of therapy;
(e) Client age, gender, pregnancy status, or other demographics; and
(f) The least costly therapeutically equivalent alternative.
(5) The department evaluates request for authorization of covered drugs, devices, and drug-related supplies that exceed limitations in this chapter on a case-by-case basis in conjunction with subsection (4) of this section and WAC 388-501-0169.
(6) If a provider needs authorization to dispense a covered drug outside of normal state business hours, the provider may dispense the drug without authorization only in an emergency. The department must receive justification from the provider within seventy-two hours of the fill date, excluding weekends and Washington state holidays, to be paid for the emergency fill.
(7) The department may remove authorization requirements under WAC 388-530-3000 for, but not limited to, the following:
(a) Prescriptions written by specific practitioners based on consistent high quality of care; or
(b) Prescriptions filled at specific pharmacies and billed to the department at the pharmacies' lower acquisition cost.
(8) Authorization requirements in WAC 388-530-3000 are not a denial of service.
(9) Rejection of a claim due to the authorization requirements listed in WAC 388-530-3000 is not a denial of service.
(10) When a claim requires authorization, the pharmacy provider must request authorization from the department. If the pharmacist fails to request authorization as required, the department does not consider this a denial of service.
(11) Denials that result as part of the authorization process will be issued by the department in writing.
(12) The department's authorization:
(a) Is a decision of medical appropriateness; and
(b) Does not guarantee payment.
[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.700, 2008 c 245. 08-21-107, § 388-530-3200, filed 10/16/08, effective 11/16/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 07-20-049, § 388-530-3200, filed 9/26/07, effective 11/1/07.]
(a) "Birthing center" means a specialized facility licensed as a childbirth center by the department of health (DOH) under chapter 246-349 WAC.
(b) "Bundled services" means services integral to the major procedure that are included in the fee for the major procedure. Under this chapter, certain services which are customarily bundled must be billed separately (unbundled) when the services are provided by different providers.
(c) "Facility fee" means the portion of ((
department's payment for the hospital or birthing center
charges. This does not include (( MAA's)) the department's
payment for the professional fee defined below.
(d) "Global fee" means the fee ((
MAA)) the department
pays for total obstetrical care. Total obstetrical care
includes all bundled antepartum care, delivery services and
(e) "High-risk" pregnancy means any pregnancy that poses a significant risk of a poor birth outcome.
(f) "Professional fee" means the portion of ((
department's payment for services that rely on the provider's
professional skill or training, or the part of the
reimbursement that recognizes the provider's cognitive skill. (See WAC 388-531-1850 for reimbursement methodology.)
MAA)) The department covers full scope medical
maternity care and newborn delivery services to
fee-for-service clients who qualify for categorically needy
(CN) or medically needy (MN) scope of care (see WAC 388-462-0015 for client eligibility). Clients enrolled in
(( an MAA)) the department managed care plan must receive all
medical maternity care and newborn delivery services through
the plan. See subsection (20) of this section for client
eligibility limitations for smoking cessation counseling
provided as part of antepartum care services.
MAA)) The department does not provide maternity
care and delivery services to its clients who are eligible
(a) Family planning only (a pregnant client under this program should be referred to the local community services office for eligibility review); or
(b) Any other program not listed in this section.
MAA)) The department requires providers of
maternity care and newborn delivery services to meet all of
the following. Providers must:
(a) Be currently licensed by the state of Washington's department of health (DOH) and/or department of licensing;
(b) Have signed core provider agreements with ((
(c) Be practicing within the scope of their licensure; and
(d) Have valid certifications from the appropriate federal or state agency, if such is required to provide these services (e.g., federally qualified health centers (FQHCs), laboratories certified through the Clinical Laboratory Improvement Amendment (CLIA), etc.).
MAA)) The department covers total obstetrical care
services (paid under a global fee). Total obstetrical care
includes all of the following:
(a) Routine antepartum care that begins in any trimester of a pregnancy;
(b) Delivery (intrapartum care/birth) services; and
(c) Postpartum care. This includes family planning counseling.
(6) When an eligible client receives all the services
listed in subsection (5) of this section from one provider,
MAA)) the department pays that provider a global obstetrical
(7) When an eligible client receives services from more
than one provider, ((
MAA)) the department pays each provider
for the services furnished. The separate services that
(( MAA)) the department pays appear in subsection (5) of this
MAA)) The department pays for antepartum care
services in one of the following two ways:
(a) Under a global fee; or
(b) Under antepartum care fees.
MAA's)) The department's fees for antepartum care
include all of the following:
(a) Completing an initial and any subsequent patient history;
(b) Completing all physical examinations;
(c) Recording and tracking the client's weight and blood pressure;
(d) Recording fetal heart tones;
(e) Performing a routine chemical urinalysis (including all urine dipstick tests); and
(f) Providing maternity counseling.
MAA)) The department covers certain antepartum
services in addition to the bundled services listed in
subsection (9) of this section. (( MAA)) The department pays
separately for any of the following:
(a) An enhanced prenatal management fee (a fee for
medically necessary increased prenatal monitoring). ((
The department provides a list of diagnoses and/or conditions
that (( MAA)) the department identifies as justifying more
frequent monitoring visits. (( MAA)) The department pays for
either (a) or (b) of this subsection, but not both;
(b) A prenatal management fee for "high-risk" maternity
clients. This fee is payable to either a physician or a
certified nurse midwife. ((
MAA)) The department pays for
either (a) or (b) of this subsection, but not both;
(c) Necessary prenatal laboratory tests except routine chemical urinalysis, including all urine dipstick tests, as described in subsection (9)(e) of this section; and/or
(d) Treatment of medical problems that are not related to
the pregnancy. ((
MAA)) The department pays these fees to
physicians or advanced registered nurse practitioners (ARNP).
MAA)) The department covers high-risk pregnancies.
(( MAA)) The department considers a pregnant client to have a
high-risk pregnancy when the client:
(a) Has any high-risk medical condition (whether or not it is related to the pregnancy); or
(b) Has a diagnosis of multiple births.
MAA)) The department covers delivery services for
clients with high-risk pregnancies, described in subsection
(11) of this section, when the delivery services are provided
in a hospital.
MAA)) The department pays a facility fee for
delivery services in the following settings:
(a) Inpatient hospital; or
(b) Birthing centers.
MAA)) The department pays a professional fee for
delivery services in the following settings:
(a) Hospitals, to a provider who meets the criteria in subsection (4) of this section and who has privileges in the hospital;
(b) Planned home births and birthing centers.
MAA)) The department covers hospital delivery
services for an eligible client as defined in subsection (2)
of this section. (( MAA's)) The department's bundled payment
for the professional fee for hospital delivery services
(a) The admissions history and physical examination; and
(b) The management of uncomplicated labor (intrapartum care); and
(c) The vaginal delivery of the newborn (with or without episiotomy or forceps); or
(d) Cesarean delivery of the newborn.
MAA)) The department pays only a labor management
fee to a provider who begins intrapartum care and
unanticipated medical complications prevent that provider from
following through with the birthing services.
(17) In addition to ((
MAA's)) the department's payment
for professional services in subsection (15) of this section,
(( MAA)) the department may pay separately for services
provided by any of the following professional staff:
(a) A stand-by physician in cases of high risk delivery and/or newborn resuscitation;
(b) A physician assistant or registered nurse "first assist" when delivery is by cesarean section;
(c) A physician, (ARNP), or licensed midwife for newborn examination as the delivery setting allows; and/or
(d) An obstetrician/gynecologist specialist for external cephalic version and consultation.
(18) In addition to the professional delivery services
fee in subsection (15) or the global/total fees (i.e., those
that include the hospital delivery services) in subsections
(5) and (6) of this section, ((
MAA)) the department allows
additional fees for any of the following:
(a) High-risk vaginal delivery;
(b) Multiple vaginal births. ((
MAA's)) The department's
typical payment covers delivery of the first child. For each
subsequent child, (( MAA)) the department pays at fifty percent
of the provider's usual and customary charge, up to (( MAA's))
the department's maximum allowable fee; or
(c) High-risk cesarean section delivery.
MAA)) The department does not pay separately for
any of the following:
(a) More than one child delivered by cesarean section
during a surgery. ((
MAA's)) The department's cesarean section
surgery fee covers one or multiple surgical births;
(b) Postoperative care for cesarean section births. This is included in the surgical fee. Postoperative care is not the same as or part of postpartum care.
(20) In addition to the services listed in subsection
(10) of this section, ((
MAA)) the department covers counseling
for tobacco dependency for eligible pregnant women through two
months postpregnancy. This service is commonly referred to as
smoking cessation education or counseling.
MAA)) The department covers smoking cessation
counseling for only those fee-for-service clients who are
eligible for categorically needy (CN) scope of care. See (f)
of this subsection for limitations on prescribing
pharmacotherapy for eligible CN clients. Clients enrolled in
managed care may participate in a smoking cessation program
through their plan.
MAA)) The department pays a fee to certain
providers who include smoking cessation counseling as part of
an antepartum care visit or a postpregnancy office visit
(which must take place within two months following live birth,
miscarriage, fetal death, or pregnancy termination). (( MAA))
The department pays only the following providers for smoking
(ii) Physician assistants (PA) working under the guidance and billing under the provider number of a physician;
(iii) ARNPs, including certified nurse midwives (CNM); and
(iv) Licensed midwives (LM).
MAA)) The department covers one smoking cessation
counseling session per client, per day, up to ten sessions per
client, per pregnancy. The provider must keep written
documentation in the client's file for each session. The
documentation must reflect the information in (e) of this
MAA)) The department covers two levels of
counseling. Counseling levels are:
(i) Basic counseling (fifteen minutes), which includes (e)(i), (ii), and (iii) of this subsection; and
(ii) Intensive counseling (thirty minutes), which includes the entirety of (e) of this subsection.
(e) Smoking cessation counseling consists of providing
information and assistance to help the client stop smoking.
Smoking cessation counseling includes the following steps
(refer to ((
MAA's)) the department's physician-related
services billing instructions and births and birthing centers
billing instructions for specific counseling suggestions and
(i) Asking the client about her smoking status;
(ii) Advising the client to stop smoking;
(iii) Assessing the client's willingness to set a quit date;
(iv) Assisting the client to stop smoking, which includes developing a written quit plan with a quit date. If the provider considers it appropriate for the client, the "assisting" step may also include prescribing smoking cessation pharmacotherapy as needed (see (f) of this subsection); and
(v) Arranging to track the progress of the client's attempt to stop smoking.
(f) A provider may prescribe pharmacotherapy for smoking
cessation for a client when the provider considers the
treatment is appropriate for the client. ((
department covers certain pharmacotherapy for smoking
cessation as follows:
MAA)) The department covers Zyban™ only;
(ii) The product must meet the rebate requirements described in WAC 388-530-1125;
(iii) The product must be prescribed by a physician, ARNP, or physician assistant;
(iv) The client for whom the product is prescribed must be eighteen years of age or older;
(v) The pharmacy provider must obtain prior authorization
MAA)) the department when filling the prescription for
(vi) The prescribing provider must include both of the following on the client's prescription:
(A) The client's estimated or actual delivery date; and
(B) Indication the client is participating in smoking cessation counseling.
MAA's)) The department's payment for smoking
cessation counseling is subject to postpay review. See WAC 388-502-0230, Provider review and appeal, and WAC
(( 388-502-0240, Audits and the audit appeal process for
contractors/providers, for information regarding review and
appeal processes for providers)) 388-502A-1100, Provider
[Statutory Authority: RCW 74.08.090, 74.09.760, and 74.09.770. 05-01-065, § 388-533-0400, filed 12/8/04, effective 1/8/05; 02-07-043, § 388-533-0400, filed 3/13/02, effective 4/13/02. Statutory Authority: RCW 74.08.090, 74.09.760 through 74.09.800. 00-23-052, § 388-533-0400, filed 11/13/00, effective 12/14/00.]
(2) The department pays one hundred percent of the department contract price for covered eyeglass frames, lenses, and contact lenses when these items are obtained through the department's approved contractor.
(3) See WAC 388-531-1850 for professional fee payment methodology.
[Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520. 08-14-052, § 388-544-0600, filed 6/24/08, effective 7/25/08. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. 05-13-038, § 388-544-0600, filed 6/6/05, effective 7/7/05. Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, § 388-544-0600, filed 12/6/00, effective 1/6/01.]
[Statutory Authority: RCW 74.08.090, 74.09.035, and 74.50.055. 00-18-032, § 388-556-0100, filed 8/29/00, effective 9/29/00.]