reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 182 - Health Care Authority › ALL PAYER HEALTH CARE CLAIMS DATABASE › Chapter 182-70 - All payer health care claims database › PENALTIES FOR INAPPROPRIATE DISCLOSURES OR USES › Section 182-70-650 - Informal dispute resolution prior to a hearing

Current through Register Vol. 24-14, July 15, 2024
(1) The following procedures are available
				  for informal dispute resolution prior to a hearing that may make more elaborate
				  proceedings under the Administrative Procedure Act unnecessary.
(2) Settlements. Any appeal of a notice of
				  violation and recommended penalty before the director or director's desig-nee,
				  for which a hearing has not yet been held, may be resolved by settlement. The
				  respondent shall communicate his or her request to the WA-APCD program
				  director, setting forth all pertinent facts and the desired remedy. Settlement
				  negotiations shall be informal and without prejudice to rights of a participant
				  in the negotiations.
(3)
				  Stipulations. The WA-APCD program director and respondent may agree to terms of
				  any stipulation of facts, violations, and/or penalty. If a stipulation is
				  reached, the WA-APCD program director shall prepare the stipulation for
				  presentation to the director.
(a) Any
				  proposed stipulation shall be in writing and signed by each party to the
				  stipulation or his or her representative. The WA-APCD program director shall
				  sign for the authority. Any stipulation shall be provided no later than three
				  business days preceding the hearing.
(b) The director has the option of accepting,
				  rejecting, or modifying the proposed stipulation or asking for additional facts
				  to be presented. If the director accepts the stipulation or modifies the
				  stipulation with the agreement of the parties, the director shall enter an
				  order in conformity with the terms of the stipulation. If the director rejects
				  the stipulation or one or both of the parties does not agree to the director's
				  proposed modifications to the stipulation, then the hearing shall be scheduled
				  and held.
Washington Administrative Code › Title 182 - Health Care Authority › ALL PAYER HEALTH CARE CLAIMS DATABASE › Chapter 182-70 - All payer health care claims database › PENALTIES FOR INAPPROPRIATE DISCLOSURES OR USES › Section 182-70-655 - Hearing and final order

Current through Register Vol. 24-14, July 15, 2024
For penalties imposed under WAC
					 182-70-600,
					 the WA-APCD program director or the director's designee conducts a hearing and
					 prepares a final order in accordance with WAC 182-526-0206.
Statutory Authority:
						RCW
						43.371.070(1)(h). WSR
						18-15-002, §
												82-75-655,
						filed 7/5/18, effective 8/5/18.
Washington Administrative Code › Title 182 - Health Care Authority › ALL PAYER HEALTH CARE CLAIMS DATABASE › Chapter 182-70 - All payer health care claims database › PENALTIES FOR INAPPROPRIATE DISCLOSURES OR USES › Section 182-70-660

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
						RCW
						43.371.070(1)(h). WSR
						18-15-002, §
												82-75-660, filed
						7/5/18, effective 8/5/18.
Washington Administrative Code › Title 182 - Health Care Authority › ALL PAYER HEALTH CARE CLAIMS DATABASE › Chapter 182-70 - All payer health care claims database › PENALTIES FOR INAPPROPRIATE DISCLOSURES OR USES › Section 182-70-665 - Posting of information related to inappropriate disclosure or use of protected information

Current through Register Vol. 24-14, July 15, 2024
(1) Except as
				  provided in subsection (2) of this section, the authority will maintain a
				  website to provide public access to information related to the inappropriate
				  disclosure or use of protected information. For each complaint for which an
				  investigation is conducted, the authority will post the complaint, the
				  information that the lead organization provided to the authority pursuant to
				  WAC 182-70-610(5), investigation report and final disposition of the complaint.
				  In addition, if the complaint finds a violation, the authority will post the
				  notice of violation and the final hearing order, if a hearing is
				  requested.
(2) If any of the
				  records specified for posting in subsection (1) of this section contains
				  confidential or protected information, that information is privileged and not
				  subject to disclosure under the Public Records Act, chapter 42.56 RCW, and will
				  be redacted from any documents posted on the authority website.
Statutory Authority:
						RCW
						43.371.070(1)(h). WSR
						18-15-002, §
												82-75-665,
						filed 7/5/18, effective 8/5/18.
Washington Administrative Code › Title 182 - Health Care Authority › ALL PAYER HEALTH CARE CLAIMS DATABASE › Chapter 182-70 - All payer health care claims database › AUDITS › Section 182-70-700 - Purpose of audits

Current through Register Vol. 24-14, July 15, 2024
There are two primary areas for which audits may be
					 performed to ensure compliance with laws and rules related to the
					 WA-APCD.
(1) Audits may be performed
				  to determine if data suppliers are in compliance with the requirements for the
				  submission of data to the WA-APCD including, but not limited to:
(a) Compliance with the data submission guide
				  including, but not limited to, accuracy of financial fields;
(b) Data integrity, as opposed to data
				  quality checks that the data vendor performs using thresholds and
				  variances;
(c) Finding data that is
				  missing or being withheld from submission into the WA-APCD; and
(d) Documenting the process for determining
				  the number of Washington covered persons for each line of business in order to
				  ensure that data suppliers are not artificially creating lines of business with
				  small numbers of covered lives in order to meet the minimum threshold for
				  exclusion to report.
Washington Administrative Code › Title 182 - Health Care Authority › ALL PAYER HEALTH CARE CLAIMS DATABASE › Chapter 182-70 - All payer health care claims database › AUDITS › Section 182-70-705 - When an audit may be commenced

Current through Register Vol. 24-14, July 15, 2024
(1) The
				  authority may initiate a random audit to ensure compliance with data release
				  requirements. A data requestor may not be subject to a random audit more
				  frequently than once every three years.
(2) The authority may initiate an audit of a
				  data supplier or data requestor upon notice that one of the following events
				  has occurred:
(a) Reports from the data
				  vendor that there is a material change, without justification or a reasonable
				  basis for the change provided by the data supplier, in the number of claims
				  submitted from a data supplier. Before submitting a report under this
				  subsection, the data vendor should have worked with the data supplier to cure
				  any inadvertent data submission issues.
(b) Reports from the data vendor that certain
				  types of claims are missing for a data supplier.
(c) Notice that the data requestor or data
				  user is publishing data in reports that are not compliant with data use
				  agreements. Violations of the data use agreements are subject to penalties in
				  accordance with the process set forth in this chapter .
(d) Notice that the data requestor or data
				  user is publishing PFI or PHI not in compliance with state or federal
				  requirements.
(e) Other occurrence
				  that could indicate that the data supplier or data requestor is not in
				  compliance with the requirements in law or rule regarding the
				  WA-APCD.
Washington Administrative Code › Title 182 - Health Care Authority › ALL PAYER HEALTH CARE CLAIMS DATABASE › Chapter 182-70 - All payer health care claims database › AUDITS › Section 182-70-715 - Audit guide

Current through Register Vol. 24-14, July 15, 2024
(1) The authority
				  shall develop the audit guide with input from the data vendor, lead
				  organization, and stakeholders. The audit guide shall include, but is not
				  limited to, the following topics:
(a) The
				  audit standards that will be used for all audits to ensure compliance with
				  generally accepted auditing practices;
(b) The process that will be used to select
				  an auditor, including the auditor qualifications, process to identify and
				  address conflicts of interest;
(c)
				  Specific contract terms that should be included in any contract with an auditor
				  including retention and destruction process for working papers.
Washington Administrative Code › Title 182 - Health Care Authority › ALL PAYER HEALTH CARE CLAIMS DATABASE › Chapter 182-70 - All payer health care claims database › AUDITS › Section 182-70-720 - Audit findings of a violation

Current through Register Vol. 24-14, July 15, 2024
(1)
				  If the audit finds that any person has violated laws, rules or data use
				  agreements, the WA-APCD program director shall require an investigation be
				  conducted in accordance with WAC 182-70-615. If the investigation determines
				  that a violation or violations have occurred, the authority will take
				  appropriate action as set forth in this chapter.
(2) In addition to any other penalties
				  authorized by law or rule, the audited party may be required to pay the cost of
				  the audit if, after an investigation conducted pursuant to this chapter, a
				  violation is found. The subject of the audit may contest the requirement to pay
				  the cost of the audit or the amount requested using the appeal process set
				  forth in this chapter for the appeal of penalties.
Statutory Authority:
						RCW 43.371.070.
						WSR 18-22-095, §
												82-75-720,
						filed 11/5/18, effective 12/6/18.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-100 - Problem Gambling › Section 182-100-0100 - Problem gambling and gambling disorder treatment services

Current through Register Vol. 24-14, July 15, 2024
(1) Under RCW
				41.05.-750, the Washington state health care authority (HCA) administers a
				program to:
(a) Prevent and treat problem
				gambling and gambling disorder; and
(b) Train professionals to identify and treat
				problem gambling issues and gambling disorders. Training must be administered
				by a qualified person who has training and experience in treatment services for
				people experiencing a problem gambling issue or gambling disorder.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-110 - PARTNERSHIP ACCESS LINE AND PSYCHIATRIC CONSULTATION LINE › Section 182-110-0100 - General

Current through Register Vol. 24-14, July 15, 2024
(1) The Washington
				state health care authority (authority), the University of Washington
				department of psychiatry and behavioral sciences, and Seattle children's
				hospital administer the partnership access lines described in
				RCW
				71.24.061, relating to mental health services
				for children and the treatment of depression in pregnant women and new
				mothers.
(2) The authority and the
				University of Washington department of psychiatry and behavioral sciences
				administer the psychiatric consultation line described in
				RCW
				71.24.062 to give certain providers on-demand
				access to psychiatric and substance use disorder clinical consultation for
				adult patients.
(3) The authority
				or its designee:
(a) Determines the
				administrative costs for each program identified in subsections (1) and (2) of
				this section;
(b) Calculates the
				proportion of clients that are covered by programs administered under chapter
				74.09 RCW; and
(c) Collects a
				proportionate share of program costs that are not for covered lives from the
				assessed entities under contract with the authority as medicaid managed care
				organizations.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-110 - PARTNERSHIP ACCESS LINE AND PSYCHIATRIC CONSULTATION LINE › Section 182-110-0200 - Definitions

Current through Register Vol. 24-14, July 15, 2024
For the purposes of this chapter:
(1) "Assessed entity" means:
(a) Health carriers, as defined in
				RCW
				48.43.005;
(b) Self-funded multiple employer welfare
				arrangements, as defined in
				RCW
				48.125.010; and
(c) Employers or other entities that provide
				health care in Washington, including self-funding entities or employee welfare
				benefit plans.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-110 - PARTNERSHIP ACCESS LINE AND PSYCHIATRIC CONSULTATION LINE › Section 182-110-0300 - Registration requirements

Current through Register Vol. 24-14, July 15, 2024
(1) An
				assessed entity must register with the authority or its designee and provide
				the required contact information. Reporting entities must comply with the
				authority's or its designee's processes for registering and submitting data, as
				outlined in the data submission guide published on the authority's or its
				designee's website.
(2)
				Reregistration is required only if there is a change in the contact information
				previously provided. Assessed entities are responsible for maintaining current
				and accurate contact information with the authority or its designee.
(3) Failure to register and provide or
				maintain accurate contact information with the authority or its designee may
				result in an assessed entity's inability to submit required data in compliance
				with this chapter.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-110 - PARTNERSHIP ACCESS LINE AND PSYCHIATRIC CONSULTATION LINE › Section 182-110-0400 - Data reporting

Current through Register Vol. 24-14, July 15, 2024
(1) Beginning
				July 1, 2021, no later than the end of forty-five calendar days after the end
				of each calendar quarter, an assessed entity must submit to the authority or
				its designee, in the required format, the total number of Washington resident
				covered lives for each calendar month from the prior quarter.
(2) An assessed entity must immediately
				notify the authority or its designee if it identifies a covered lives reporting
				error.
(3) Each assessed entity
				must collect and maintain the data in a manner consistent with applicable state
				and federal health information privacy laws.
(4) Failure to report accurate data to the
				authority or its designee may result in an assessed entity's inability to
				maintain compliance with this chapter.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-110 - PARTNERSHIP ACCESS LINE AND PSYCHIATRIC CONSULTATION LINE › Section 182-110-0500 - Assessment

Current through Register Vol. 24-14, July 15, 2024
Each assessed entity receives a quarterly invoice for its
				  share of the total amount of program costs that are for the proportion of the
				  entity's covered lives. Entities must timely send payment to fund the
				  partnership access lines described in
				  RCW
				  71.24.061 and the psychiatric consultation
				  line described in
				  RCW
				  71.24.062.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-115 - Certified peer counselor › Section 182-115-0100 - Certified peer counselor-General

Current through Register Vol. 24-14, July 15, 2024
(1)
				The authority recognizes a person as a certified peer counselor who can provide
				medicaid-reimbursable peer counseling services when the person meets the
				requirements in WAC 182-115-0200.
(2) Certified peer counselors who provide
				services to people enrolled in medicaid must be under the clinical supervision
				of a mental health professional and/or substance use disorder professional who
				understands rehabilitation and recovery. The clinical supervisor's expertise
				should be aligned with the needs of the populations served by the certified
				peer counselor.
(3) Certified peer
				counselors must provide services to people enrolled in medicaid under a
				licensed community behavioral health agency as defined in WAC
				246-341-0200
				and certified under WAC
				246-341-0724.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-115 - Certified peer counselor › Section 182-115-0200 - Certified peer counselor-Application, training, examination, and authority approval

Current through Register Vol. 24-14, July 15, 2024
(1) Applicants
				applying to become a certified peer counselor with the authority must meet all
				of the following:
(a) Self-identify as a
				person with lived experience in behavioral health recovery or as a parent or
				legal guardian of a child under the age of 18 who experienced behavioral health
				challenges;
(b) Demonstrate they
				have been well-grounded in their own recovery for at least one year and be
				willing to tell their recovery story;
(c) Demonstrate basic reading and writing
				comprehension;
(d) Meet the minimum
				education requirements of a high school diploma or GED. The authority may grant
				a waiver of this requirement;
(e)
				Be 18 years of age or older;
(f) Be
				credentialed as an agency affiliated counselor under chapter 18.19
				RCW;
(g) Complete specialized
				training provided by or contracted through the authority. If the person was
				trained by trainers approved by the department of social and health services
				before October 1, 2004, and has met the requirements in (a), (b), and (f) of
				this subsection by January 31, 2005, the person is exempt from completing this
				specialized training; and
(h)
				Successfully pass the authority's examination.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-125 - Tribal-designated crisis responder › Section 182-125-0100 - Tribal-designated crisis responder

Current through Register Vol. 24-14, July 15, 2024
(1) The
				Washington state health care authority (the authority) appoints a
				tribal-designated crisis responder upon request and after consultation with one
				or more federally recognized Indian tribes or after meeting and conferring with
				one or more Indian health care providers. This rule does not apply to matters
				heard in tribal court.
(2) This
				rule does not apply to counties' independent authority to appoint designated
				crisis responders in collaboration with tribes under
				RCW
				71.05.020(15). This rule
				does not eliminate the responsibility of the agency providing crisis services
				to serve American Indian/Alaska Native individuals.
(3) A tribal-designated crisis responder must
				meet the qualifications under
				RCW
				71.05.760.
(4) A tribe or Indian health care provider
				located in Washington state may request that the authority appoint a qualified
				person as a tribal-designated crisis responder by submitting a letter of
				recommendation that includes the following:
(a) The person's name and contact
				information.
(b) An explanation of
				how the person meets the qualifications under
				RCW
				71.05.760, including dates on which the
				person completed or will complete required designated crisis responder
				training.
(c) A copy of the policy
				and procedures for the designated crisis responder services. The policy and
				procedures must describe the tribe's or Indian health care provider's plan for
				training, back-up, information sharing, and communication for designated crisis
				responders who respond to private homes or nonpublic settings.
(d) A copy of the tribe's or Indian health
				care provider's behavioral health agency license and certification or
				attestation to provide emergency involuntary detention services under WAC
				246-341-0810,
				including documentation of any applicable exemptions under WAC
				246-341-0302.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-130 - Family initiated treatment (FIT) › Section 182-130-0100 - Family initiated treatment (FIT)-Appropriately trained professional person

Current through Register Vol. 24-14, July 15, 2024
(1) An
				appropriately trained professional person means a psychiatrist, psychologist,
				psychiatric nurse, social worker, licensed marriage and family therapist,
				licensed mental health counselor, psychiatric advanced registered nurse
				practitioner, and other mental health professionals as defined by the
				department of health under chapter 71.05 RCW.
(2) An appropriately trained professional
				person can also be a substance use disorder professional, or those who hold
				co-occurring substance use disorder and mental health credentials as defined by
				the department of health under chapter 18.205 RCW.
(3) The professional person evaluating for
				purposes of admission or outpatient treatment for a mental health disorder must
				hold mental health or co-occurring credentials.
(4) The professional person evaluating for
				purposes of admission or outpatient treatment for a substance use disorder must
				hold substance use disorder or co-occurring credentials.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-135 - Recovery residence program › Section 182-135-0100 - Purpose and scope

Current through Register Vol. 24-14, July 15, 2024
(1) The health care
				authority operates programs to support people who are in recovery from
				substance use disorder. Recovery residences provide housing for people in
				recovery from substance use disorder. These residences are safe, established
				homes that meet the standards set by the authority for the accreditation
				process.
(2) This chapter addresses
				recovery residence referrals, accreditation, and start-up loans.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-135 - Recovery residence program › Section 182-135-0110 - Definitions

Current through Register Vol. 24-14, July 15, 2024
The following definitions apply to this chapter:
"Accredited"
for the purposes of this chapter,
				  means an organization approved by the National Alliance of Recovery Residences
				  (NAAR).
"Appropriate client"
means a person in recovery
				  from substance use disorder who meets the requirements established by a
				  recovery residence on the registry.
"Approved recovery residence"
means a home-like
				  environment free from alcohol and illicit drug use with a focus on peer
				  support, assistance with obtaining addiction services, and other recovery
				  services and support that:
(a) Is
				approved through the health care authority's contracted accreditation process;
				and
(b) Appears on the
				registry.
"Licensed or certified service provider"
means a
				  person licensed, certified, registered, or otherwise authorized by the
				  department of health and the relevant health profession, to provide services
				  under Title 18 RCW.
"Refer"
means providing an appropriate client
				  with option-based information pertaining to potential recovery residences and
				  does not include client placement.
"Registry"
means a list of recovery residences
				  that are accredited and agency-approved, as described in
				  RCW
				  41.05.760.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-135 - Recovery residence program › Section 182-135-0120 - Recovery residence referrals

Current through Register Vol. 24-14, July 15, 2024
A licensed or certified service provider may refer an
				  appropriate client only to a recovery residence that is included in the
				  registry, except as provided in WAC
				  182-135-0130.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-135 - Recovery residence program › Section 182-135-0130 - Approved recovery residences-Exception

Current through Register Vol. 24-14, July 15, 2024
If an approved recovery residence is not located in an
				  appropriate client's desired county, a licensed or certified service provider
				  may refer the client to another suitable placement or
				  service.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-135 - Recovery residence program › Section 182-135-0200 - Operating fund

Current through Register Vol. 24-14, July 15, 2024
(1)
Purpose.
The health care authority has established the recovery
				residence operating revolving loan to maintain an ongoing revolving fund, as
				authorized by 42 U.S.C. Sec.
				300x-25(a) and as
				described in
				RCW
				41.05.762.
(2)
Fund.
The fund identified in
				subsection (1) of this section lends money to pay for the operating start-up
				costs associated with recovery residence programs. These costs include, but are
				not limited to:
(a) One-time rent or mortgage
				payments;
(b) Utility security
				deposits;
(c) Salaries for on-site
				staff;
(d) Minimal maintenance
				costs; and
(e) Furnishings
				purchased for recovery residences.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-400 - Public option plans (Cascade care select) › Section 182-400-0100 - Public option hospital participation-Purpose and scope

Current through Register Vol. 24-14, July 15, 2024
(1) The Washington
				health benefit exchange, in partnership with the health care authority,
				administers public purchasing of the Washington state public option plans known
				as Cascade Care Select.
(2) Each
				hospital should consider all valid offers from public option plans to ensure
				compliance with this chapter and to avoid sanctions by failing to contract with
				at least one public option plan.
(3) In accordance with RCW 41.05.405,
				beginning in plan year 2023, a hospital that receives payments through a
				medical assistance program under chapter 74.09 RCW, or a public employees
				benefits board (PEBB) or a school employees benefits board (SEBB) program under
				chapter 41.05 RCW must contract with at least one carrier offering public
				option plans to provide in-network coverage to enrollees, if the hospital
				received a valid offer to contract with a carrier offering public option plans
				to provide in-network services.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-400 - Public option plans (Cascade care select) › Section 182-400-0200 - Definitions

Current through Register Vol. 24-14, July 15, 2024
For the purposes of this chapter:
"Authority" means the Washington state health care
				  authority.
"Carrier" is defined in
				  RCW
				  48.43.005.
"Health benefit exchange" means the Washington state health
				  benefit exchange established in
				  RCW
				  43.71.020.
"Hospital" means any hospital licensed under chapter 70.41
				  RCW that receives payment for services provided:
(a) To enrollees in the public employees benefits program or
				  school employees benefits program under chapter 41.05 RCW; or
(b) Through a medical assistance program under chapter 74.09
				  RCW.
"Parties" means carriers and hospitals as defined in this
				  chapter.
"Plan year" means the 12-month period beginning on January
				  1st of each year and ending on December 31st of the same year.
"Public option plan" means a qualified health plan contracted
				  by or offered in a response to a procurement issued by the authority under
				  RCW
				  41.05.410.
"Valid offer to contract" means:
(a) A written offer made by a carrier to a hospital to enter
				  into a contract with the carrier to provide in-network coverage to enrollees of
				  the carrier's public option plans; and
(b) The carrier's offer must contain sufficient information
				  so that a reasonable person would understand that a good faith offer has been
				  made. The carrier must, at a minimum, include the reimbursement rate offered in
				  a manner that constitutes a legally binding document that the parties could
				  execute.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-400 - Public option plans (Cascade care select) › Section 182-400-0300 - Enforcement

Current through Register Vol. 24-14, July 15, 2024
(1)
Compliance.
The authority conducts investigations, as needed, to
				ensure compliance with this chapter.
(2)
Investigations.
The
				authority may open an investigation:
(a) When
				the authority receives information from a carrier that a hospital failed to
				contract with that carrier to provide in-network coverage to enrollees of the
				carrier's public option plans after making a valid offer to contract;
(b) When there are no public option plans
				available in the county where the hospital is located; or
(c) On a case-by-case basis at the
				authority's sole discretion.
Washington Administrative Code › Title 182 - Health Care Authority › BEHAVIORAL HEALTH › Chapter 182-400 - Public option plans (Cascade care select) › Section 182-400-0400 - Notice of sanction appeal process

Current through Register Vol. 24-14, July 15, 2024
(1)
				The process described in this section applies only if a party receives a
				written sanction notice from the authority for noncompliance with this
				chapter.
(2) The authority must
				receive a party's appeal within 28 calendar days of the date the party received
				the notice of sanction.
(a) To file an appeal,
				a party must send a written request for an administrative hearing to the
				address listed on the notice of sanction in a manner that provides proof of
				receipt.
(b) The request for the
				administrative hearing must provide a copy of the notice of sanction in
				dispute.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-500 - Medical definitions › Section 182-500-0005 - Definitions

Current through Register Vol. 24-14, July 15, 2024
Chapter 182-500 WAC contains definitions of words and phrases
				  used in rules for medical assistance and other health care programs. When a
				  term is not defined in this chapter, other agency or agency's designee WAC, or
				  state or federal law, the medical definitions found in the Taber's Cyclopedic
				  Medical Dictionary will apply. For general terms not defined in this chapter,
				  other agency or agency's designee WAC, or state or federal law, the definitions
				  in Webster's New World Dictionary apply. If a definition in this chapter
				  conflicts with a definition in another chapter of Title 182 WAC, the definition
				  in the specific WAC prevails.
11-14-075, recodified as §
											182-500-0005, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and 2011 1st sp.s. c 15. 11-14-053,
					 § 388-500-0005, filed 6/29/11, effective 7/30/11. Statutory Authority:
					 RCW
					 34.05.353(2)(d),
					 74.08.090, and chapters 74.09,
					 74.04 RCW. 08-11-047, §
					 388-500-0005, filed 5/15/08, effective 6/15/08. Statutory Authority:
					 RCW
					 74.04.050,
					 74.04.057,
					 74.08.090,
					 74.09.530,
					 74.04.005,
					 74.08.331,
					 74.08A.010,
					 [74.08A.]100,[74.08A.]210 , [74.08A.]230, 74.09.510, 74.12.255,
					 Public Law
					 104-193 (1997) and the Balanced Budget Act [of]
					 1997. 98-15-066, § 388-500-0005, filed 7/13/98, effective 7/30/98.
					 Statutory Authority:
					 RCW
					 74.08.090. 95-22-039 (Order 3913, #100246),
					 § 388-500-0005, filed 10/25/95, effective 10/28/95; 94-10-065 (Order
					 3732), § 388-500-0005, filed 5/3/94, effective 6/3/94. Formerly parts of
					 WAC 388-80-005, 388-82-006, 388-92-005 and
					 388-93-005.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-500 - Medical definitions › Section 182-500-0015 - Medical assistance definitions - B

Current through Register Vol. 24-14, July 15, 2024
"Benefit package"
means the set of health care
				  service categories included in a client's health care program. See WAC
				  182-501-0060.
"Benefit period"
means the time period used to
				  determine whether medicare can pay for covered Part A services. A benefit
				  period begins the first day a beneficiary receives inpatient hospital or
				  extended care services 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
				  published fee schedules. The provider must submit a report which describes the
				  nature, extent, time, effort and equipment necessary to deliver the
				  service.
11-14-075, recodified as §
											182-500-0015, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and 2011 1st sp.s. c 15. 11-14-053,
					 § 388-500-0015, filed 6/29/11, effective
					 7/30/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-500 - Medical definitions › Section 182-500-0025 - Definitions-D

Current through Register Vol. 24-14, July 15, 2024
"Delayed certification"
means agency or the
				  agency's designee approval of a person's eligibility for medical assistance
				  made after the established application processing time limits.
"Dental consultant"
means a dentist employed or
				  contracted by the agency or the agency's designee.
"Department"
means the state department of
				  social and health services.
"Disabled"
means unable to engage in any
				  substantial gainful activity by reason of any medically determinable physical
				  or mental impairment that:
(a) Can be expected to result in death;
(b) Has lasted or can be expected to last for a continuous
				  period of not less than twelve months; or
(c) In the case of a child age seventeen or younger, means
				  any physical or mental impairment of comparable severity.
Decisions on SSI-related disability are subject to the
				  authority of federal statutes and rules codified at 42 U.S.C.
Sec 1382c and 20 C.F.R., parts 404 and 416, as amended, and
				  controlling federal court decisions, which define the old-age, survivors, and
				  disability insurance (OASDI) and SSI disability standard and determination
				  process. See WAC
				  182-500-0015
				  for definition of "blind."
"Domestic partner"
means an adult who meets the
				  requirements for a valid state registered domestic partnership as established
				  by
				  RCW
				  26.60.030 and who has been issued a
				  certificate of state registered domestic partnership from the Washington
				  secretary of state.
"Dual eligible client"
means a client who has
				  been found eligible as a categorically needy (CN) or medically needy (MN)
				  medicaid client and is also a medicare beneficiary. This does not include a
				  client who is only eligible for a medicare savings program as described in
				  chapter 182-517 WAC.
11-14-075, recodified as §
											182-500-0025, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and 2011 1st sp.s. c 15. 11-14-053,
					 § 388-500-0025, filed 6/29/11, effective
					 7/30/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-500 - Medical definitions › Section 182-500-0035 - Medical assistance definitions-F

Current through Register Vol. 24-14, July 15, 2024
"Fee-for-service (FSS)"
- The general payment
				  method the agency or agency's designee uses to pay for covered medical services
				  provided to clients, except those services covered under the agency's prepaid
				  managed care programs.
"Fiscal intermediary"
means an organization
				  having an agreement with the federal government to process medicare claims
				  under Part A.
"Full-scope coverage"
means that the client is
				  entitled to the benefits in the scope of service categories under WAC
				  182-501-0060.
11-14-075, recodified as §
											182-500-0035, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and 2011 1st sp.s. c 15. 11-14-053,
					 § 388-500-0035, filed 6/29/11, effective
					 7/30/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-500 - Medical definitions › Section 182-500-0040 - Medical assistance definitions - G

Current through Register Vol. 24-14, July 15, 2024
"Grandfathered client"
means a
				  noninstitutionalized person who meets all current requirements for medicaid
				  eligibility except the criteria for blindness or disability; and:
(1) Was eligible for medicaid in December
				1973 as blind or disabled whether or not the person was receiving cash
				assistance in December 1973;
(2)
				Continues to meet the criteria for blindness or disability and other conditions
				of eligibility used under the medicaid plan in December 1973; or
(3) Was an institutionalized person who:
(a) Was eligible for medicaid in December
				1973, or any part of that month, as an inpatient of a medical institution or a
				resident of a facility that is known as an intermediate care facility that was
				participating in the medicaid program and for each consecutive month after
				December 1973; and
(b) Continues to
				meet the requirements for medicaid eligibility that were in effect under the
				state's plan in December 1973 for institutionalized persons and remains
				institutionalized.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-500 - Medical definitions › Section 182-500-0045 - Medical assistance definitions - H

Current through Register Vol. 24-14, July 15, 2024
"Health benefit exchange"
means the
				  public-private partnership created pursuant to chapter 43.71 RCW.
"Health insurance premium tax credit (HIPTC)"
is
				  a premium tax credit that is refundable and can also be paid in advance from
				  the Internal Revenue Service to a taxpayer's insurance company to help cover
				  the cost of premiums for a taxpayer enrolled in a qualified health plan (QHP)
				  through the health benefit exchange. This tax credit is specified in Section
				  36B of the Internal Revenue Code of 1986.
"Health maintenance organization (HMO)"
means an
				  entity licensed by the office of the insurance commissioner to provide
				  comprehensive medical services directly to an eligible enrolled client in
				  exchange for a premium paid by the agency on a prepaid capitation risk
				  basis.
"Health care professional"
means a provider of
				  health care services licensed or certified by the state in which they
				  practice.
"Health care service category"
means a grouping
				  of health care services listed in the table in WAC
				  182-501-0060. A health care
				  service category is included or excluded depending on the client's medical
				  assistance benefits package.
"Home health agency"
means an agency or
				  organization certified under medicare to provide comprehensive health care on a
				  part-time or intermittent basis to a patient in the patient's place of
				  residence.
"Hospital"
means an entity that is licensed as
				  an acute care hospital in accordance with applicable state laws and rules, or
				  the applicable state laws and rules of the state in which the entity is located
				  when the entity is out-of-state, and is certified under Title XVIII of the
				  federal Social Security Act. The term "hospital" includes a medicare or
				  state-certified distinct rehabilitation unit or a psychiatric
				  hospital.
11-14-075, recodified as §
											182-500-0045, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and 2011 1st sp.s. c 15. 11-14-053,
					 § 388-500-0045, filed 6/29/11, effective
					 7/30/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-500 - Medical definitions › Section 182-500-0050 - Washington apple health definitions-I "Ineligible spouse"

Current through Register Vol. 24-14, July 15, 2024
see "spouse" in WAC
				  182-500-0100.
"Institution"
means an entity that furnishes (in
				  single or multiple facilities) food, shelter, and some treatment or services to
				  four or more people unrelated to the proprietor. Eligibility for a Washington
				  apple health program may vary depending upon the type of institution in which
				  an individual resides. For the purposes of apple health programs, "institution"
				  includes all the following:
(1)
"Institution for mental diseases (IMD)"
- A hospital, nursing
				facility, or other institution of more than 16 beds that is primarily engaged
				in providing diagnosis, treatment or care of people with mental diseases,
				including medical attention, nursing care and related services. An IMD may
				include inpatient substance use disorder (SUD) facilities of more than 16 beds
				which provide residential treatment for SUD.
(2)
"Intermediate care facility for
				individuals with intellectual disabilities (ICF/IID)"
- An institution
				or distinct part of an institution that is:
(a) Defined in
				42 C.F.R.
				440.150;
(b) Certified to provide ICF/IID services
				under 42 C.F.R.
				483, Subpart I; and
(c) Primarily for the diagnosis, treatment,
				or rehabilitation for people with intellectual disabilities or a related
				condition.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-500 - Medical definitions › Section 182-500-0065 - Definitions-L

Current through Register Vol. 24-14, July 15, 2024
"Limitation extension"
see WAC
				  182-501-0169.
"Limited casualty program (LCP)"
means the
				  medically needy (MN) program.
"Long-term civil commitment"
means inpatient
				  mental health treatment for clients on 90-day or 180-day court orders whose
				  treatment is authorized by the agency in agency-contracted
				  beds.
11-14-075, recodified as §
											182-500-0065, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and 2011 1st sp.s. c 15. 11-14-053,
					 § 388-500-0065, filed 6/29/11, effective
					 7/30/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-500 - Medical definitions › Section 182-500-0075 - Medical assistance definitions-N

Current through Register Vol. 24-14, July 15, 2024
"National correct coding initiative (NCCI)"
is a
				  national standard for the accurate and consistent description of medical goods
				  and services using procedural codes. The standard is based on coding
				  conventions defined in the American Medical Association's Current Procedural
				  Terminology (CPT®) manual, current standards of medical and surgical coding
				  practice, input from professional societies, and analysis of current coding
				  practices. The Centers for Medicare and Medicaid Services (CMS) maintain NCCI
				  policy. Information can be found at:
http://www.cms.hhs.gov/NationalCorrectCodInitEd/
.
"National provider indicator (NPI)"
is a unique
				  identification number for covered health care providers.
"NCCI edit"
is a software step used to determine
				  if a claim is billing for a service that is not in accordance with federal and
				  state statutes, federal and state regulations, agency or the agency's
				  designee's fee schedules, billing instructions, and other publications. The
				  agency or the agency's designee has the final decision whether the NCCI edits
				  allow automated payment for services that were not billed in accordance with
				  governing law, NCCI standards or agency or agency's designee policy.
"Nonapplying spouse"
see "spouse" in WAC
				  182-500-0100.
"Nonbilling provider"
see definition for
				  provider in WAC
				  182-500-0085.
"Noncovered service"
see "covered service" in
				  WAC 182-500-0020.
"Nonphysician practitioner"
means the following
				  professionals who work in collaboration with an ordering physician: Nurse
				  practitioner, clinical nurse specialist, certified nurse midwife, or physician
				  assistant.
"Nursing facility"
see "institution" in WAC
				  182-500-0050.
"Nursing facility long-term care services"
are
				  services in a nursing facility when a person does not meet the criteria for
				  rehabilitation. Most long-term care assists people with support services. (Also
				  called custodial care.)
"Nursing facility rehabilitative services"
are
				  the planned interventions and procedures which constitute a continuing and
				  comprehensive effort to restore a person to the person's former functional and
				  environmental status, or alternatively, to maintain or maximize remaining
				  function.
Statutory
				  Authority: 42 C.F.R.
				  455.410,
				  RCW
				  41.05.021. WSR 13-19-037, §
										182-500-0075, filed 9/11/13,
				  effective 10/12/13. WSR 11-14-075, recodified as §
										182-500-0075, filed 6/30/11,
				  effective 7/1/11. Statutory Authority:
				  RCW
				  74.08.090 and
				  2011 1st sp.s. c
				  15 . WSR 11-14-053, § 388-500-0075, filed
				  6/29/11, effective 7/30/11. WSR 13-18-003, §
										182-500-0075, filed 8/21/2013,
				  effective 9/21/2013
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-500 - Medical definitions › Section 182-500-0080 - Medical assistance definitions - O

Current through Register Vol. 24-14, July 15, 2024
"Ordering and referring provider"
means any
				  physician or other health care professional who orders or refers items or
				  services for clients eligible for Washington's health care programs
				  administered by the agency.
"Outpatient"
means a patient receiving care in a
				  hospital outpatient setting or a hospital emergency department, or away from a
				  hospital such as in a physician's office or clinic, the patient's own home, or
				  a nursing facility.
"Overhead costs"
means those costs that have
				  been incurred for common or joint objectives and cannot be readily identified
				  with a particular final cost objective. Overhead costs that are allocated must
				  be clearly distinguished from other functions and identified as a benefit to a
				  direct service.
Statutory
				  Authority: 42 C.F.R.
				  455.410,
				  RCW
				  41.05.021. WSR 13-19-037, §
										182-500-0080, filed 9/11/13,
				  effective 10/12/13. WSR 11-14-075, recodified as §
										182-500-0080, filed 6/30/11,
				  effective 7/1/11. Statutory Authority:
				  RCW
				  74.08.090 and
				  2011 1st sp.s. c
				  15 . WSR 11-14-053, § 388-500-0080, filed
				  6/29/11, effective 7/30/11. WSR 13-18-003, §
										182-500-0080, filed 8/21/2013,
				  effective 9/21/2013
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-500 - Medical definitions › Section 182-500-0090 - Medical assistance definitions-Q

Current through Register Vol. 24-14, July 15, 2024
"Qualified health plan (QHP)"
means a health
				  insurance plan that has been certified by the Washington health benefit
				  exchange to meet at minimum the standards described in 45 C.F.R. Part 156,
				  Subpart C and
				  RCW
				  43.71.065 and offered in accordance with the
				  process described in 45 C.F.R. Part 155, Subpart K and
				  RCW
				  43.71.065.