WSR 15-21-063 PERMANENT RULES HEALTH CARE AUTHORITY (Washington Apple Health) [Filed October 19, 2015, 12:12 p.m., effective November 19, 2015] Effective Date of Rule: Thirty-one days after filing.
Purpose: The amendments replace outdated references to Title 388 WAC, MAA, etc., clarify language, add definitions for "billing instructions" and "provider guides," and remove terms that are not used in Title 182 WAC.
Citation of Existing Rules Affected by this Order: Amending WAC 182-500-0015, 182-500-0085, and 182-500-0105.
Adopted under notice filed as WSR 15-18-072 on August 28, 2015.
Changes Other than Editing from Proposed to Adopted Version: In WAC 182-500-0085, the agency struck the following language because providers do not need prior authorization to write a prescription: "Prior authorization" is the requirement that a provider must request, on behalf of a client and when required by rule or agency billing instructions, the agency or the agency's designee's approval to provide a health care service or write a prescription before the client receives the health care service, or prescribed drug, device, or drug-related supply. The agency or the agency's designee's approval is based on medical necessity. Receipt of prior authorization does not guarantee payment. Expedited prior authorization and limitation extension are types of prior authorization."
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 3, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 3, Repealed 0.
Date Adopted: October 19, 2015.
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-500-0015 Medical assistance definitions—B.
"Benefit package" means the set of health care service categories included in a client's ((eligibility)) health care program. See ((the table in WAC 388-501-0060)) WAC 182-501-0060.
"Benefit period" means the time period used ((in determining)) to determine whether medicare can pay for covered Part A services. A benefit period begins the first day a beneficiary ((is furnished)) receives inpatient hospital or extended care services ((by)) from a qualified provider. The benefit period ends when the beneficiary has not been an inpatient of a hospital or other facility primarily providing skilled nursing or rehabilitation services for sixty consecutive days. There is no limit to the number of benefit periods a beneficiary may receive. Benefit period also means a "spell of illness" for medicare payments.
"Billing instructions" means provider guides. See WAC 182-500-0085.
"Blind" is a category of medical program eligibility that requires:
(a) A central visual acuity of 20/200 or less in the better eye with the use of a correcting lens((,)); or
(b) A field of vision limitation so the widest diameter of the visual field subtends an angle no greater than twenty degrees from central.
"By report (BR)" means a method of payment in which the agency or the agency's designee determines the amount it will pay for a service when the rate for that service is not included in the agency's ((or the agency's designee(s))) published fee schedules. The provider must submit a (("))report((")) which describes the nature, extent, time, effort and((/or)) equipment necessary to deliver the service.
AMENDATORY SECTION (Amending WSR 14-06-045, filed 2/26/14, effective 3/29/14)
WAC 182-500-0085 Medical assistance definitions—P.
"Patient transportation" means client transportation to ((and/))or from covered health care services under federal and state health care programs.
"Physician" means a doctor of medicine, osteopathy, naturopathy, or podiatry who is legally authorized to perform the functions of the profession by the state in which the services are performed.
"Prescribing provider" means ((any physician or other)) a health care professional authorized by law or rule to prescribe drugs ((for current clients of Washington's health care programs administered by the agency)) to Washington apple health (WAH) clients.
"Prior authorization" is the requirement that a provider must request, on behalf of a client and when required by rule or agency billing instructions, the ((agency's)) agency or the agency's designee's approval to ((render)) provide a health care service ((or write a prescription in advance of)) before the client ((receiving)) receives the health care service ((or)), prescribed drug, device, or drug-related supply. The ((agency's)) agency or the agency's designee's approval is based on medical necessity. Receipt of prior authorization does not guarantee payment. Expedited prior authorization and limitation extension are types of prior authorization.
"Prosthetic device((s))" means a preventive, replacement, corrective, or supportive device((s)) prescribed by a physician or other licensed practitioner ((of the healing arts)), within the scope of his or her practice ((as defined by)) under state law ((to:
"Provider" means an institution, agency, or person that is licensed, certified, accredited, or registered according to Washington state law((s and rules)), and has:
(((1) Has)) (a) A signed core provider agreement or ((signed a)) contract with the agency or the agency's designee, and is authorized to provide health care, goods, and((/or)) services to ((medical assistance)) WAH clients; or
(((2) Has)) (b) Authorization from a managed care organization (MCO) that contracts with the agency or the agency's designee to provide health care, goods, and((/or)) services to eligible ((medical assistance)) WAH clients enrolled in the MCO plan.
"Provider guide" means an agency publication that describes a specific benefit covered under WAH, which includes client eligibility verification instructions, provider responsibilities, authorization requirements, coverage, billing, and how to complete and submit claims.
"Public institution" see "institution" in WAC 182-500-0050.
AMENDATORY SECTION (Amending WSR 14-06-068, filed 2/28/14, effective 3/31/14)
WAC 182-500-0105 Medical assistance definitions—T.
(("Tax filing terms":
(1) "Tax filer" means a person who expects to file a tax return.
(2))) "Tax dependent" means a person for whom ((another person claims a deduction for a personal exemption under Section 151 of the Internal Revenue Code of 1986 for a taxable year)) a tax filer claims an exemption on his or her federal income tax return. A tax dependent may be either a ((qualified)) qualifying child or a ((qualified)) qualifying relative ((as defined below and under Section 152 of the Internal Revenue Code of 1986 for a taxable year.
(a) "Qualified child" means a child who meets the criteria to be claimed as a tax dependent based on one of the following relationships to the tax filer: Natural, adoptive, step, or foster child; natural, adoptive, step or half-sibling; or a descendant of any of the above; and meets the following criteria:
(i) The child is:
(A) Under the age of nineteen;
(B) Under the age of twenty-four and a full-time student; or
(C) Any age and permanently or totally disabled.
(ii) The child lived in the tax filer's household for more than one-half of the year;
(iii) The child provided for less than one-half of his/her own support for the year; and
(iv) The child is not filing a joint tax return for the year unless the return is filed only as a claim for a refund of taxes.
(b) "Qualified relative" means a person who:
(i) Cannot be claimed as a qualifying child or the qualifying child of another tax filer;
(ii) Has lived in the tax filer's household for the full year or is related to the tax filer in one of the ways listed below and the relationship has not been ended by death or divorce:
(A) The tax filer's child, stepchild, foster child, or a descendant of any of them;
(B) A sibling, half-sibling or step-sibling;
(C) A parent, grandparent, or other direct ancestor, but not a foster parent;
(D) A niece, nephew, aunt, or uncle;
(E) In-law relationships (son, daughter, father, mother, brother or sister-in-law).
(iii) Has gross income below an annual threshold set by the Internal Revenue Service (IRS) (three thousand nine hundred dollars for tax year 2013 with some exceptions). See IRS publication 501 for more information; and
(iv) Relies on the tax filer to pay over one-half of their total support for the year.
(3) "Nonfiler" means a person who is not required to file a tax return and also includes those who are not required to file but choose to file for another purpose, such as to claim a reimbursement of taxes paid)) under 26 U.S.C. Sec. 152 for a taxable year.
"Tax filer" means a person who expects to file a federal income tax return.
"Third party" means an entity other than the medicaid agency or the agency's designee that ((is or)) may be liable to pay all or part of the cost of health care for a Washington apple health (WAH) client.
"Third-party liability (TPL)" means the legal responsibility of an identified third party or parties to pay all or part of the cost of health care for a ((Washington apple health ())WAH(())) client. ((A WAH client's obligation to help establish TPL is described in)) See client obligations in establishing TPL under WAC 182-503-0540.
"Title XIX" is the portion of the federal Social Security Act, 42 U.S.C. 1396 et seq., that authorizes funding to states for health care programs. Title XIX is also called medicaid.
"Title XXI" is the portion of the federal Social Security Act, 42 U.S.C. 1397aa et seq., that authorizes funding to states for the children's health insurance program (CHIP).
"Transfer of assets" means changing ownership or title of an asset such as income, real property, or personal property by one of the following:
(((1))) (a) An intentional act that changes ownership or title; or
(((2))) (b) A failure to act that results in a change of ownership or title.
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