HEALTH CARE AUTHORITY
[Filed June 27, 2022, 1:39 p.m., effective July 28, 2022]
Effective Date of Rule: Thirty-one days after filing.
Purpose: The agency is correcting subsection (3)(c) of this rule to align with the medicaid state plan.
Citation of Rules Affected by this Order: Amending WAC 182-550-6000.
Adopted under notice filed as WSR 22-11-057 on May 16, 2022.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 1, Repealed 0.
Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 1, Repealed 0.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: June 27, 2022.
AMENDATORY SECTION(Amending WSR 22-04-051, filed 1/27/22, effective 2/27/22)
WAC 182-550-6000Outpatient hospital services—Conditions of payment and payment methods.
(1) The medicaid agency pays hospitals for covered outpatient hospital services provided to eligible clients when the services meet the provisions in WAC 182-550-1700. All professional medical services must be billed according to chapter 182-531 WAC.
(2) To be paid for covered outpatient hospital services, a hospital provider must:
(a) Have a current core provider agreement with the agency;
(b) Bill the agency according to the conditions of payment under WAC 182-502-0100;
(c) Bill the agency according to the time limits under WAC 182-502-0150; and
(d) Meet program requirements in other applicable WAC and the agency's published issuances.
(3) The agency does not pay separately for any services:
(a) Included in a hospital's room charges;
(b) Included as covered under the agency's definition of room and board (e.g., nursing services). See WAC 182-550-1050; or
(c) Related to an inpatient hospital admission and provided within one calendar day of a client's inpatient admission ((or discharge)).
(4) The agency does not pay:
(a) A hospital for outpatient hospital services when a managed care plan is contracted with the agency to cover these services;
(b) More than the "acquisition cost" ("A.C.") for HCPCS (health care common procedure coding system) codes noted in the outpatient fee schedule; or
(c) For cast room, emergency room, labor room, observation room, treatment room, and other room charges in combination when billing periods for these charges overlap.
(5) The agency uses the outpatient weighted costs-to-charges (OWCC) rate to pay for covered outpatient services provided in a critical access hospital (CAH). See WAC 182-550-2598.
(6) Hospitals must provide documentation as required or requested by the agency.
(7) All hospital providers must present final charges to the agency within 365 days of the "statement covers period from date" shown on the claim. The state of Washington is not liable for payment based on billed charges received beyond 365 days from the "statement covers period from date" shown on the claim.