HEALTH CARE AUTHORITY
[Filed November 6, 2019, 3:52 p.m., effective December 7, 2019]
Effective Date of Rule: Thirty-one days after filing.
Purpose: The agency is revising this section to strike subsection (2)(a) to align with changes in 42 U.S.C. 1396a (a)(25)(E) which removed prenatal care from the list of medical services that the agency pays and then seeks reimbursements from a liable third party. State medicaid agencies must use standard coordination of benefits cost avoidance when processing prenatal services claims.
Citation of Rules Affected by this Order: Amending WAC 182-501-0200.
Adopted under notice filed as WSR 19-20-116 on October 2, 2019.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.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: November 6, 2019.
AMENDATORY SECTION(Amending WSR 16-23-021, filed 11/4/16, effective 1/1/17)
WAC 182-501-0200Third-party resources.
(1) The medicaid agency requires a provider to seek timely reimbursement from a third party when a client has available third-party resources, except as described under subsections (2) and (3) of this section.
(2) The agency pays for medical services and seeks reimbursement from a liable third party when the claim is for any of the following:
(a) ((Prenatal care;
(b))) Labor, delivery, and postpartum care (except inpatient hospital costs) for a pregnant woman; or
(((c)))(b) Preventive pediatric services as covered under the early and periodic screening, diagnosis and treatment program.
(3) The agency pays for medical services and seeks reimbursement from any liable third party when both of the following apply:
(a) The provider submits to the agency documentation of billing the third party and the provider has not received payment after thirty days from the date of services; and
(b) The claim is for a covered service provided to a client on whose behalf the office of support enforcement is enforcing ((an absent))a noncustodial parent to pay support. For the purpose of this section, "is enforcing" means the ((absent))noncustodial parent either:
(i) Is not complying with an existing court order; or
(ii) Received payment directly from the third party and did not pay for the medical services.
(4) The provider may not bill the agency or the client for a covered service when a third party pays a provider the same amount as or more than the agency rate.
(5) When the provider receives payment from a third party after receiving reimbursement from the agency, the provider must refund to the agency the amount of the:
(a) Third-party payment when the payment is less than the agency's maximum allowable rate; or
(b) Agency payment when the third-party payment is equal to or more than the agency's maximum allowable rate.
(6) The agency does not pay for medical services if third-party benefits are available to pay for the client's medical services when the provider bills the agency, except under subsections (2) and (3) of this section.
(7) The client is liable for charges for covered medical services that would be paid by the third-party payment when the client either:
(a) Receives direct third-party reimbursement for the services; or
(b) Fails to execute legal signatures on insurance forms, billing documents, or other forms necessary to receive insurance payments for services rendered. See WAC 182-503-0540 for assignment of rights.
(8) The agency considers an adoptive family to be a third-party resource for the medical expenses of the birth mother and child only when there is a written contract between the adopting family and either the birth mother, the attorney, the provider, or the adoption service. The contract must specify that the adopting family will pay for the medical care associated with the pregnancy.
(9) A provider cannot refuse to furnish covered services to a client because of a third-party's potential liability for the services.
(10) For third-party liability on personal injury litigation claims, the agency or managed care organization (MCO) is responsible for providing medical services under WAC 182-501-0100.