WSR 15-01-056 PERMANENT RULES HEALTH CARE AUTHORITY (Washington Apple Health) [Filed December 10, 2014, 10:55 a.m., effective January 10, 2015] Effective Date of Rule: Thirty-one days after filing.
Purpose: To revise and clarify provider overpayment dispute policy.
Citation of Existing Rules Affected by this Order: Amending WAC 182-502-0230.
Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.
Adopted under notice filed as WSR 14-21-180 on October 22, 2014.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.
Date Adopted: December 10, 2014.
Kevin M. Sullivan
Rules Coordinator
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-502-0230 Provider ((payment reviews and dispute rights)) overpayment disputes—General.
(((1) As authorized by chapters 43.20B and 74.09 RCW, the department monitors and reviews all providers who furnish health care services to eligible clients. For the purposes of this section, health care services includes treatment, equipment, related supplies, and drugs. The department may review all documentation and/or data related to payments made to providers for health care services for eligible clients and determine whether the providers are complying with the rules and regulations of the program(s). Examples of provider reviews are:
(a) A review of all records and/or payments for medical assistance clients;
(b) A random sampling of billing and/or records for medical assistance clients; and/or
(c) A review focused on selected records for medical assistance clients.)) (1) This section applies to provider overpayment disputes with providers who furnish health care services to Washington apple health clients, except those overpayment disputes to which chapter 182-502A WAC applies. For the purposes of this section:
(a) "Agency" means the health care authority and its designees.
(b) "Provider" has the same meaning as vendor in RCW 41.05A.010(5).
(2) ((The department may)) If the medicaid agency determines that a ((provider's billing does not comply with program rules and regulations. As a result of that determination)) provider was overpaid, the ((department)) agency may take any of the following actions((, or others as appropriate)):
(a) ((Conduct prepay reviews of all claims the provider submits to the department)) Review claims, encounters, or payments;
(b) Refer the provider to the ((department's auditors (see chapter 388-502A WAC))) agency's office of program integrity;
(c) Refer the provider to the Washington state medicaid fraud control unit;
(d) Refer the provider to the appropriate state health ((professions quality assurance commission)) care professional discipline authority;
(e) Terminate the provider's participation in ((medical assistance programs (see WAC 388-502-0030))) Washington apple health;
(g) In the event of a prepay review, suspend some or all payments;
(h) Adjust or void an improper claim, encounter, or payment;
(i) Recover any moneys that the provider received as a result of overpayments as authorized under chapter ((43.20B)) 41.05A RCW; and
(j) Any other action authorized by Title 182 WAC.
(3) A provider ((who disagrees with a department action regarding overpayment recovery)) may ((request)) contest an overpayment by requesting a hearing ((to dispute the action(s) per RCW 43.20B.675)).
(((a))) (4) The hearing request ((for hearing)) must:
(a) Be in writing; ((and
(i) Must be received by the department within twenty-eight days of the date of the notice of action(s), by certified mail (return receipt) or other means that provides proof of delivery to:
Office of Financial Recovery
P.O. Box 9501
Olympia, WA 98507-5501; and
(ii) State the reason(s) why the provider thinks the action(s) are incorrect.
(b) The office of administrative hearings schedules and conducts the hearing under the Washington Administrative Procedure Act, chapter 34.05 RCW, and chapter 388-02 WAC. The department offers a prehearing/alternative dispute conference prior to the hearing.
(c) The office of financial recovery collects any amount the provider is ordered to repay.))
(b) Identify each overpayment being contested;
(c) State each reason why the provider thinks the overpayment is incorrect;
(d) Include documentation to support the provider's position; and
(e) Include a copy of the overpayment notice.
(5) The hearing request must be served on the agency at the address specified in the overpayment notice, in a manner which provides proof of receipt, no later than twenty-eight calendar days after the provider received the overpayment notice.
(6) The hearing is conducted under the Administrative Procedure Act and chapter 182-526 WAC.
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