WA CARES FUND PROGRAM

(1) This chapter establishes the responsibilities of the health care authority in the long-term services and supports program known as WA cares fund program as identified in RCW 50B.04.020(2).

(2) Department of social and health services program rules can be found under chapter 388-116 WAC.

(3) Employment security department program rules can be found under Title 192 WAC.

The definitions in this section apply throughout this chapter.

Approved services has the same meaning as defined in WAC 388-116-1010.

Benefit unit has the same meaning as defined in RCW 50B.04.010.

Eligible beneficiary has the same meaning as defined in RCW 50B.04.010.

Long-term services and supports (LTSS) provider has the same meaning as defined in RCW 50B.04.010.

Preauthorization means the process and product of verifying and granting permission to the LTSS provider to provide an approved service to the eligible beneficiary at a rate or amount agreed upon between the LTSS provider and eligible beneficiary. The preauthorization is a service agreement between the beneficiary and the LTSS provider.

Program has the same meaning as defined in RCW 50B.04.010.

(1) The health care authority (HCA) tracks and ensures that payments for LTSS services do not exceed an eligible beneficiary's total available program benefit units.

(2) HCA pays a claim for approved services that have been preauthorized by the eligible beneficiary, when the LTSS provider:

(a) Meets the applicable requirements in chapter 388-116 WAC;

(b) Submits the claim through HCA's payment system; and

(c) Submits the original claim and any subsequent claims adjustments:

(i) No more than 60 days after the latest end-date of the preauthorization; and

(ii) After the service has been provided.

If an eligible beneficiary is also an apple health (medicaid) client, the provider must first seek timely payment from the beneficiary's WA cares benefit units before billing apple health (medicaid) for approved services.

(1) The health care authority (HCA) ensures preauthorized LTSS services are provided through service verification and audits and recoups any inappropriate payments and refers potential fraud to law enforcement.

(2) Methods. Program integrity activity methods include, but are not limited to:

(a) Service verifications;

(b) Audits of records and review of other documentation to determine compliance with laws, regulations, and billing guides; and

(c) Interviews with providers, eligible beneficiaries, and witnesses.

(3) Audit period. HCA may conduct program integrity activities involving claims submitted for payment to HCA anytime up to six years after the date of service.

(4) Scope and focus. HCA determines the scope and focus of any program integrity activity.

(5) Selecting claims and information to be evaluated. HCA may evaluate records or other information relevant to validating whether the LTSS provider received inappropriate payment.

(6) Cooperation.

(a) An LTSS provider must cooperate with an audit.

(b) An LTSS provider must provide information and submit records requested by HCA by the due date in the request.

(c) An LTSS provider must submit records electronically unless otherwise requested, or granted permission by HCA to submit a hard copy, and must follow the instructions for records submission included in the request.

(d) If sent electronically, records must be sent using a secure method uploaded through HCA's managed file transfer (MFT) site.

(e) If the LTSS provider does not comply with the audit, HCA may issue a final notice of findings and assess an overpayment.

(7) HCA does not reimburse any costs an LTSS provider incurs complying with program integrity activities.

(1) When the health care authority (HCA) completes the review under WAC 182-600-0500, HCA may do any of the following:

(a) Deny and recover improperly paid claims;

(b) Instruct the LTSS provider to submit additional information or submit a new claim;

(c) Issue a final notice assessing an overpayment which the LTSS provider may appeal under WAC 182-600-0700;

(d) Refer an overpayment to the department of social and health services office of financial recovery for collection;

(e) Refer suspected fraud to law enforcement.

(2) LTSS providers must keep documentation to prove the services billed were delivered and payment was appropriate. Providers must retain all records supporting claims for a minimum of six years from the date of service, or longer if the law requires or an audit or investigation is in progress. Failure to keep this documentation may result in recoupment of the payment.

(1) The administrative hearing process is governed by chapters 34.05 RCW and 182-526 WAC.

(2) An LTSS provider who disagrees with the health care authority's (HCA) action to recoup inappropriate payments under RCW 50B.04.020 (2)(b) may request an administrative hearing under chapter 182-526 WAC.

(3) An LTSS provider does not have an administrative hearing right for the denial of payment of a claim.

(4) HCA does not recoup overpayments until an order is final.

(5) Throughout the administrative hearings process, the LTSS provider bears the burden of proving by a preponderance of the evidence that it has complied with applicable laws, rules, regulations, and agreements.