WSR 16-04-051
(Washington Apple Health)
[Filed January 28, 2016, 7:32 a.m., effective March 1, 2016]
Effective Date of Rule: March 1, 2016.
Purpose: WAC 182-550-4400 (2)(i) was revised to remove the list of approved hospitals for bariatric surgery. The list was outdated. Providers may refer to the agency's inpatient hospital provider guide or the agency's web site for the most updated list of approved hospitals for bariatric surgery. WAC 182-550-4400 (2)(f) was revised to change the authorization requirements for administrative days.
Citation of Existing Rules Affected by this Order: Amending WAC 182-550-4400.
Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.
Adopted under notice filed as WSR 16-01-186 on December 22, 2015.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.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: January 28, 2016.
Wendy Barcus
Rules Coordinator
AMENDATORY SECTION (Amending WSR 14-12-047, filed 5/29/14, effective 7/1/14)
WAC 182-550-4400 Services—Exempt from DRG payment.
(1) Inpatient services are exempt from the diagnosis-related group (DRG) payment method only if they qualify for payment methods specifically mentioned in other sections of this chapter or in this section.
(2) Subject to the restrictions and limitations in this section, the agency exempts the following services for medicaid and CHIP clients from the DRG payment method. This policy also applies to covered services paid through medical care services (MCS) and any other state-administered program, except when otherwise indicated in this section. The exempt services are:
(a) Alcohol or other drug detoxification services when provided in a hospital having a detoxification provider agreement with the agency to perform these services.
(b) Hospital-based intensive inpatient detoxification, medical stabilization, and drug treatment services provided to chemical-using pregnant (CUP) women by a certified hospital. These are medicaid program services and are not covered or funded by the agency through MCS or any other state-administered program.
(c) Acute physical medicine and rehabilitation (acute PM&R) services.
(d) Psychiatric services. A mental health designee that arranges to pay a hospital directly for psychiatric services may use the agency's payment methods or contract with the hospital to pay using different methods. Claims not paid directly through a mental health designee are paid through the agency's payment system.
(e) Chronic pain management treatment provided in a hospital approved by the agency to provide that service.
(f) Administrative day services. ((For patient days during an inpatient stay where no acute care services were provided, a hospital may request an administrative day designation on a case-by-case basis.)) The agency pays administrative days for one or more days of a hospital stay in which an acute inpatient or observation level of care is not medically necessary, and a lower level of care is appropriate. The administrative day((s)) rate is based on the statewide average daily medicaid nursing facility ((per diem)) rate, which is adjusted annually. The agency may designate part of a client's stay to be paid an administrative day rate upon review of the claim or the client's medical record, or both.
(g) Inpatient services recorded on a claim grouped by the agency to a DRG for which the agency has not published an all-patient DRG (AP-DRG) or all-patient refined DRG (APR-DRG) relative weight. The agency will deny payment for claims grouped to DRG 469, DRG 470, APR DRG 955, or APR DRG 956.
(h) Organ transplants that involve heart, intestine, kidney, liver, lung, allogeneic bone marrow, autologous bone marrow, pancreas, or simultaneous kidney/pancreas. The agency pays hospitals for these organ transplants using the ratio of costs-to-charges (RCC) payment method. The agency maintains a list of DRGs which qualify as transplants on the agency's web site.
(i) Bariatric surgery performed in hospitals that meet the criteria in WAC 182-550-2301. The agency pays hospitals for bariatric surgery on a per case rate basis for clients in medicaid and state-administered programs when the services are prior authorized and take place at an approved hospital. ((The agency approves bariatric services at Sacred Heart Medical Center, the University of Washington Medical Center, and the Oregon Health Sciences University and may approve other hospitals based on agency discretion.)) See WAC 182-550-3000 and 182-550-3470.