reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-4000 - Covered - Wheelchairs - General

Current through Register Vol. 24-14, July 15, 2024
(1)
				The medicaid agency covers, with prior authorization, manual and power-drive
				wheelchairs for clients who reside at home. For clients who reside in a skilled
				nursing facility, see WAC
				182-543-5700.
(2) For manual or power-drive wheelchairs for
				clients who reside at home, requests for prior authorization must include all
				of the following completed forms:
(a) General
				Information for Authorization form HCA 13-835). The agency's electronic forms
				are available online (see WAC
				182-543-7000,
				Authorization);
(b) A Prescription
				Form HCA 13-794); and
(c) Medical
				Necessity for Wheelchair Purchase (for home clients only) form HCA 13-727) from
				the client's physician or therapist. The date on this form HCA 13-727) must not
				be prior to the date on the Prescription Form HCA 13-794).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-4100 - Covered - Wheelchairs - Manual

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency covers the rental or purchase of a
				  manual wheelchair for a home client who is nonambulatory or has limited
				  mobility and requires a wheelchair to participate in normal daily activities.
				  For clients who reside in a skilled nursing facility, see WAC
				  182-543-5700.
(1) The agency determines the type of manual
				wheelchair for a home client as follows:
(a)
				A standard wheelchair if the client's medical condition requires the client to
				have a wheelchair to participate in normal daily activities;
(b) A standard lightweight wheelchair if the
				client's medical condition is such that the client:
(i) Cannot self-propel a standard weight
				wheelchair; or
(ii) Requires
				custom modifications that cannot be provided on a standard weight
				wheelchair.
(c) A
				high-strength, lightweight wheelchair for a client:
(i) Whose medical condition is such that the
				client cannot self-propel a lightweight or standard weight wheelchair;
				or
(ii) Requires custom
				modifications that cannot be provided on a standard weight or lightweight
				wheelchair.
(d) A heavy
				duty wheelchair for a client who requires a specifically manufactured
				wheelchair designed to:
(i) Support a person
				weighing three hundred pounds or over; or
(ii) Accommodate a seat width up to
				twenty-two inches wide (not to be confused with custom heavy duty
				wheelchairs).
(e) A
				custom heavy duty wheelchair for a client who requires a specifically
				manufactured wheelchair designed to:
(i)
				Support a person weighing three hundred pounds or over; or
(ii) Accommodate a seat width over twenty-two
				inches wide.
(f) A rigid
				wheelchair for a client:
(i) With a medical
				condition that involves severe upper extremity weakness;
(ii) Who has a high level of activity;
				and
(iii) Who is unable to
				self-propel any of the above categories of wheelchair.
(g) A custom manufactured wheelchair for a
				client with a medical condition requiring wheelchair customization that cannot
				be obtained on any of the categories of wheelchairs listed in this
				section.
(h) Pediatric
				wheelchairs/positioning strollers having a narrower seat and shorter depths
				more suited to pediatric patients, usually adaptable to modifications for a
				growing child.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-4200 - Covered wheelchairs-Power-drive

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency pays for medically necessary power-drive
				  wheelchairs when prior authorized.
(1)
Adults.
The medicaid agency pays for power-drive wheelchairs for
				clients age twenty-one and older when the prescribing physician certifies that
				the following clinical criteria are met:
(a)
				The client can independently and safely operate a power-drive
				wheelchair;
(b) The client's
				medical condition prevents the client from self-propelling any of the
				wheelchairs listed in the manual wheelchair category; and
(c) A power-drive wheelchair will provide the
				client the only means of independent mobility in any of the settings where the
				client's normal life activities take place.
The agency also pays for power wheelchairs on a case-by-case
				  basis that are determined medically necessary and when prior authorized as
				  described in WAC
				  182-501-0165.
				  The agency determines medical necessity based on documentation submitted by the
				  provider.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-4300 - Wheelchairs-Modifications, accessories, and repairs

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency pays for, with prior
				authorization, wheelchair accessories and modifications that are specifically
				identified by the manufacturer as separate line item charges. To receive
				payment, providers must submit the following to the agency:
(a) A completed General Information for
				Authorization form (HCA 13-835). The agency's electronic forms are available
				online (see WAC
				182-543-7000,
				Authorization);
(b) A completed
				Prescription Form (HCA 13-794);
(c)
				A completed Medical Necessity for Wheelchair Purchase (for home clients only)
				form (HCA 13-727). The date on this form (HCA 13-727) must not be dated prior
				to the date on the Prescription Form (HCA 13-794);
(d) The make, model, and serial number of the
				wheelchair to be modified;
(e) The
				modification requested; and
(f) Any
				specific information regarding the client's medical condition that necessitates
				the modification.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-4400 - Complex rehabilitation technology

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency pays for, with prior
				authorization, individually configured, complex rehabilitation technology (CRT)
				products.
(2) CRT must be supplied
				by a CRT supplier with the appropriate taxonomy number to bill for the
				items.
(3) Each site that a company
				operates must employ at least one CRT professional who has been certified by
				the Rehabilitation Engineering and Assistive Technology Society of North
				America (RESNA).
(4) The client
				must be evaluated by a licensed health care provider who performs specialty
				evaluations within their scope of practice (occupational or physical
				therapists) and who does not have a financial relationship with the supplier.
(a) At the evaluation, a CRT professional
				must also be present from the company ordering the equipment; or
(b) The CRT provider must be present at the
				evaluation to:
(i) Assist in selection of the
				appropriate CRT item(s); and
(ii)
				Provide training in the use of the selected items.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-5000 - Prosthetics/ orthotics

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency pays for, without prior authorization (PA), the following prosthetics
				and orthotics. Items that meet the definition of medical equipment may be
				covered under the requirements for medical equipment. Prosthetics and orthotics
				that do not meet those definitions are covered, with stated limitations:
(a) Thoracic-hip-knee-ankle orthosis (THKAO)
				standing frame - One every five years.
(b) Preparatory, above knee "PTB" type
				socket, non-alignable system, pylon, no cover, SACH foot plaster socket, molded
				to model - One per lifetime, per limb.
(c) Preparatory, below knee "PTB" type
				socket, non-alignable system, pylon, no cover, SACH foot thermoplastic or
				equal, direct formed - One per lifetime, per limb.
(d) Socket replacement, below the knee,
				molded to patient model - One per twelve-month period, per limb.
(e) Socket replacement, above the knee/knee
				disarticulation, including attachment plate, molded to patient model -One per
				twelve-month period, per limb.
(f)
				All other prosthetics and orthotics are limited to one per twelve-month period
				per limb.
(g) Prosthetics and
				orthotics beyond these limits may be prior authorized when medically necessary,
				as defined in WAC
				182-500-0070.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-5500 - Medical supplies and related services

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency pays for the following medical supplies
				  and related services without prior authorization unless otherwise
				  specified:
(1) Antiseptics and
				germicides:
(a) Alcohol (isopropyl) or
				peroxide (hydrogen) - One pint per month;
(b) Alcohol wipes (box of two hundred) - One
				box per month;
(c) Betadine or
				pHisoHex solution - One pint per month;
(d) Betadine or iodine swabs/wipes (box of
				one hundred) - One box per month;
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-5700 - Medical equipment for clients in skilled nursing facilities

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency's skilled nursing facility per diem rate, established in chapters 74.46
				RCW, 388-96, and 388-97 WAC, includes any reusable and disposable medical
				supplies that may be required for a skilled nursing facility client, unless
				otherwise specified within this section.
(2) The agency pays for the following medical
				equipment outside of the skilled nursing facility per diem rate, subject to the
				limitations in this section:
(a) Manual or
				power-drive wheelchairs (including CRT);
(b) Speech generating devices (SGD);
				and
(c) Specialty beds.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-6000

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-543-6000, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.04.050. 11-14-052, §
					 388-543-6000, filed 6/29/11, effective
					 8/1/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-7000 - Authorization

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency requires providers to obtain authorization for medical equipment as
				required in this chapter, in chapters 182-501 and 182-502 WAC, and in published
				billing guides and provider notices or when the clinical criteria required in
				this chapter are not met.
(a) The agency
				considers requests for prior authorization (PA) for any item meeting the
				definition of medical equipment, and PA is granted when the service is
				medically necessary as defined in WAC
				182-500-0070.
(b) For prior authorization (PA), a provider
				must submit a written request to the agency as specified in the agency's
				published billing guides (see WAC
				182-543-7100
				). All requests for prior authorization must be accompanied by a completed
				General Information for Authorization form (HCA 13-835) in addition to any
				program specific forms as required within this chapter. The agency's electronic
				forms are available online at
http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx
.
(c) For expedited prior authorization (EPA),
				a provider must meet the clinically appropriate EPA criteria outlined in the
				agency's published billing guides. The appropriate EPA number must be used when
				the provider bills the agency (see WAC
				182-543-7200
				).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-7100 - Prior authorization

Current through Register Vol. 24-14, July 15, 2024
(1) The
				medicaid agency requires providers to obtain prior authorization for certain
				medical equipment and services before delivering the equipment or service to
				the client, except for dual-eligible medicare/medicaid clients when medicare is
				the primary payer. The equipment or service must also be delivered to the
				client before the provider bills the agency.
(2) All prior authorization requests must be
				accompanied by a completed General Information for Authorization form (HCA
				13-835), in addition to any program specific agency forms as required within
				this chapter. Agency forms are available online at
http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx
.
(3) When the agency receives the initial
				request for prior authorization, the prescription for the medical equipment or
				services must not be older than six months from the date the agency receives
				the request.
(4) The agency
				requires certain information from providers in order to prior authorize the
				purchase or rental of equipment. This information includes, but is not limited
				to:
(a) The manufacturer's name;
(b) The equipment model and serial
				number;
(c) A detailed description
				of the item; and
(d) Any
				modifications required, including the product or accessory number as shown in
				the manufacturer's catalog.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-7200 - Prior authorization for limits on amount, frequency, or duration

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency limits the amount, frequency, or duration of certain medical equipment
				and related services, and reimburses up to the stated limit without requiring
				prior authorization.
(2) Certain
				items have limitations on quantity and frequency. These limits are designed to
				avoid the need for prior authorization for items normally considered medically
				necessary and for quantities sufficient for a thirty-day supply for one
				client.
(3) The agency requires a
				provider to request prior authorization in order to exceed the stated limits
				for medical equipment and supplies that do not require prior authorization. All
				requests for prior authorization must be accompanied by a completed General
				Information for Authorization form (HCA 13-835) in addition to any program
				specific forms as required within this chapter. Agency forms are available
				online at
http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx
.
(4) The agency evaluates such requests under
				the provisions of WAC
				182-501-0169,
				and grants prior authorization when it is medically necessary, as defined in
				WAC
				182-500-0070.
11-14-075, recodified as §
											182-543-7200, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.04.050. 11-14-052, §
					 388-543-7200, filed 6/29/11, effective
					 8/1/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-7300 - Expedited prior authorization (EPA)

Current through Register Vol. 24-14, July 15, 2024
(1) The expedited prior authorization process
				(EPA) is designed to eliminate the need for written and telephonic requests for
				prior authorization for selected medical equipment procedure codes.
(2) The medicaid agency requires a provider
				to create an authorization number for EPA for selected medical equipment
				procedure codes. The process and criteria used to create the authorization
				number is explained in the agency published medical equipment-related billing
				guide. The authorization number must be used when the provider bills the
				agency.
(3) Upon request, a
				provider must provide documentation to the agency showing how the client's
				condition met the criteria for EPA.
(4) A written or telephone request for prior
				authorization is required when a situation does not meet the EPA criteria for
				selected medical equipment procedure codes.
(5) The agency may recoup any payment made to
				a provider under this section if the provider did not follow the expedited
				authorization process and criteria.
11-14-075, recodified as §
											182-543-7300, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.04.050. 11-14-052, §
					 388-543-7300, filed 6/29/11, effective
					 8/1/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-8000 - Billing general

Current through Register Vol. 24-14, July 15, 2024
(1) A provider must
				not bill the medicaid agency for the rental or purchase of medical equipment
				supplied to the provider at no cost by suppliers or manufacturers.
(2) The agency does not pay a medical
				equipment provider for medical supplies used in conjunction with a physician
				office visit. The agency pays the office physician for these supplies when
				appropriate. Refer to the agency's physician-related professional services
				billing guide.
(3) The agency does
				not pay for any prosthetics and orthotics required for surgery or placed during
				the hospital stay under this chapter. See chapter 182-550 WAC. In this
				situation, the prosthetics and orthotics are included in the hospital
				reimbursement rate.
11-14-075, recodified as §
											182-543-8000, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.04.050. 11-14-052, §
					 388-543-8000, filed 6/29/11, effective
					 8/1/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-8100 - Billing for managed care clients

Current through Register Vol. 24-14, July 15, 2024
If a fee-for-service (FFS) client enrolls in a medicaid
				  agency-contracted managed care organization (MCO), the following apply:
(1) The agency stops paying for any rented
				medical equipment on the last day of the month preceding the month in which the
				client becomes enrolled in the MCO.
(2) The plan determines the client's
				continuing need for the medical equipment and is responsible for paying the
				provider.
(3) A client may become
				an MCO enrollee before the agency completes the purchase of prescribed medical
				equipment. The agency considers the purchase complete when the product is
				delivered and the agency is notified of the serial number. If the client
				becomes an MCO enrollee before the agency completes the purchase:
(a) The agency rescinds the agency's
				authorization with the vendor until the MCO's primary care provider (PCP)
				evaluates the client; then
(b) The
				agency requires the PCP to write a new prescription if the PCP determines the
				equipment is still medically necessary as defined in WAC
				182-500-0070;
				then
(c) The MCO's applicable
				reimbursement policies apply to the purchase or rental of the
				equipment.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-8200 - Billing for clients eligible for medicare and medicaid

Current through Register Vol. 24-14, July 15, 2024
If a client is eligible for both medicare and medicaid, see
				  WAC 182-502-0110 Conditions of
				  payment and prior authorization requirements-Medicare coinsurance, copayments,
				  and deductibles.
11-14-075, recodified as §
											182-543-8200, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.04.050. 11-14-052, §
					 388-543-8200, filed 6/29/11, effective
					 8/1/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-9000 - General reimbursement

Current through Register Vol. 24-14, July 15, 2024
(1) The
				medicaid agency pays qualified providers who meet all conditions in WAC
				182-502-0100
				for medical equipment, repairs, and related services provided on a
				fee-for-service (FFS) basis as follows:
(a)
				To agency-enrolled medical equipment providers, qualified complex
				rehabilitation technology (CRT) suppliers, pharmacies, and home health agencies
				under their national provider identifier (NPI) numbers, subject to the
				limitations of this chapter, and according to the procedures and codes in the
				agency's current medical equipment billing guide;
(b) In accordance with the health care common
				procedure coding system (HCPCS) guidelines for product classification and code
				assignation; and
(c) Providers must
				code the specific brand and model of wheelchair or CRT products dispensed
				according to the centers for medicare and medicaid services' (CMS) pricing,
				data analysis, and coding (PDAC) web site.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-9100

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
					 RCW
					 41.05.021. 12-16-059, §
											182-543-9100, filed 7/30/12,
					 effective 8/30/12; 12-07-022, §
											182-543-9100, filed 3/12/12,
					 effective 4/12/12. 11-14-075, recodified as §
											182-543-9100, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.04.050. 11-14-052, §
					 388-543-9100, filed 6/29/11, effective
					 8/1/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-9200

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
					 RCW
					 41.05.021. 12-16-059, §
											182-543-9200, filed 7/30/12,
					 effective 8/30/12; 12-07-022, §
											182-543-9200, filed 3/12/12,
					 effective 4/12/12. 11-14-075, recodified as §
											182-543-9200, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.04.050. 11-14-052, §
					 388-543-9200, filed 6/29/11, effective
					 8/1/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-9300

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
					 RCW
					 41.05.021. 12-16-059, §
											182-543-9300, filed 7/30/12,
					 effective 8/30/12; 12-07-022, §
											182-543-9300, filed 3/12/12,
					 effective 4/12/12. 11-14-075, recodified as §
											182-543-9300, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.04.050. 11-14-052, §
					 388-543-9300, filed 6/29/11, effective
					 8/1/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-543 - Medical equipment, supplies, and appliances › Section 182-543-9400

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
					 RCW
					 41.05.021. 12-16-059, §
											182-543-9400, filed 7/30/12,
					 effective 8/30/12; 12-07-022, §
											182-543-9400, filed 3/12/12,
					 effective 4/12/12. 11-14-075, recodified as §
											182-543-9400, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.04.050. 11-14-052, §
					 388-543-9400, filed 6/29/11, effective
					 8/1/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-544 - Vision care › VISION CARE - CLIENTS TWENTY YEARS OF AGE AND YOUNGER › Section 182-544-0010 - Vision care - General

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency covers the vision care services listed in this chapter for clients age
				  twenty and younger, according to agency rules and subject to the limitations
				  and requirements in this chapter. The agency pays for vision care when it is:
(a) Covered;
(b) Within the scope of the client's benefit
				  package;
(c) Medically necessary as
				  defined in WAC
				  182-500-0070;
(d) Authorized, as required within this
				  chapter, chapter 182-501 WAC, and the agency's published billing instructions;
				  and
(e) Billed according to this
				  chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing
				  instructions.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-544 - Vision care › VISION CARE - CLIENTS TWENTY YEARS OF AGE AND YOUNGER › Section 182-544-0100 - Vision care - Eligible persons - Twenty years of age and younger

Current through Register Vol. 24-14, July 15, 2024
This section applies to eligible persons who are twenty
					 years of age and younger.
(1) Vision
				  care is available to persons who are eligible for services under one of the
				  Washington apple health programs listed in the table in WAC
				  182-501-0060 or are eligible for
				  the alien emergency medical (AEM) program as described in WAC
				  182-507-0110.
(2) Eligible persons who are enrolled in an
				  agency-contracted managed care organization (MCO) are eligible under
				  fee-for-service for covered vision care that is not covered by their plan ,
				  subject to the provisions of this chapter and other applicable WAC.
11-14-075, recodified as §
												182-544-0100, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.08.090. 11-11-016, § 388-544-0100,
						filed 5/9/11, effective 6/9/11. Statutory Authority:
						RCW
						74.08.090,
						74.09.510,
						74.09.520. 08-14-052, §
						388-544-0100, filed 6/24/08, effective 7/25/08. Statutory Authority:
						RCW
						74.08.090,
						74.09.510,
						74.09.520 and
						42 C.F.R.
						440.120 and
						440.225. 05-13-038, §
						388-544-0100, filed 6/6/05, effective 7/7/05. Statutory Authority:
						RCW
						74.08.090,
						74.09.510 and
						74.09.520. 01-01-010, §
						388-544-0100, filed 12/6/00, effective
						1/6/01.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-544 - Vision care › VISION CARE - CLIENTS TWENTY YEARS OF AGE AND YOUNGER › Section 182-544-0150 - Vision care - Provider requirements

Current through Register Vol. 24-14, July 15, 2024
(1)
				  Enrolled/contracted eye care providers must:
(a) Meet the requirements in chapter 182-502
				  WAC;
(b) Provide only those
				  services that are within the scope of the provider's license;
(c) Obtain all hardware (including the
				  tinting of eyeglass lenses) and contact lenses for clients from the medicaid
				  agency's designated supplier as published in the agency's current vision care
				  billing instructions; and
(d)
				  Return all unclaimed hardware and contact lenses to the agency's designated
				  supplier using a postage-paid envelope furnished by the supplier.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-544 - Vision care › VISION CARE - CLIENTS TWENTY YEARS OF AGE AND YOUNGER › Section 182-544-0250 - Vision care - Covered eye services (examinations, refractions, visual field testing, and vision therapy)

Current through Register Vol. 24-14, July 15, 2024
See WAC
					 182-531-1000 Ophthalmic
					 services.
11-14-075, recodified as §
												182-544-0250, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.08.090. 11-11-016, § 388-544-0250,
						filed 5/9/11, effective 6/9/11. Statutory Authority:
						RCW
						74.08.090,
						74.09.510,
						74.09.520. 08-14-052, §
						388-544-0250, filed 6/24/08, effective 7/25/08. Statutory Authority:
						RCW
						74.08.090,
						74.09.510,
						74.09.520 and
						42 C.F.R.
						440.120 and
						440.225. 05-13-038, §
						388-544-0250, filed 6/6/05, effective 7/7/05. Statutory Authority:
						RCW
						74.08.090,
						74.09.510 and
						74.09.520. 01-01-010, §
						388-544-0250, filed 12/6/00, effective
						1/6/01.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-544 - Vision care › VISION CARE - CLIENTS TWENTY YEARS OF AGE AND YOUNGER › Section 182-544-0300 - Vision care - Covered eyeglasses (frames and lenses) Clients age twenty and younger

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency covers eye-glasses once every twelve months for clients when the
				  following clinical criteria are met:
(a) The
				  client has a stable visual condition;
(b) The client's treatment is
				  stabilized;
(c) The prescription is
				  less than eighteen months old; and
(d) One of the following minimum correction
				  needs in at least one eye is documented in the client's file:
(i) Sphere power equal to, or greater than,
				  plus or minus 0.50 diopter;
(ii)
				  Astigmatism power equal to, or greater than, plus or minus 0.50 diopter;
				  or
(iii) Add power equal to, or
				  greater than, 1.0 diopter for bifocals and trifocals.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-544 - Vision care › VISION CARE - CLIENTS TWENTY YEARS OF AGE AND YOUNGER › Section 182-544-0325 - Vision care - Covered eyeglass frames and repairs-Clients age twenty and younger

Current through Register Vol. 24-14, July 15, 2024
(1)The medicaid
				  agency covers durable or flexible frames when the client has a diagnosed
				  medical condition that contributes to broken eyeglass frames. To receive
				  payment, the provider must order the "durable" or "flexible" frames through the
				  agency's designated supplier.
(2)
				  The agency covers all of the following for clients :
(a) Coating contract eyeglass frames to make
				  the frames nonallergenic. Clients must have a medically diagnosed and
				  documented allergy to the materials in the available eyeglass frames.
(b) Four incidental repairs to a client's
				  eyeglass frames in a calendar year. To receive payment, all of the following
				  must be met:
(i) The provider typically
				  charges the general public for the repair or adjustment;
(ii) The contractor's one year warranty
				  period has expired; and
(iii) The
				  cost of the repair does not exceed the agency's cost for replacement frames and
				  a fitting fee.
(c) Up to
				  two replacement eyeglass frames in a calendar year when the eyeglass frames
				  have been lost or broken. Lost or broken eyeglass frames must be documented in
				  the client's medical record.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-544 - Vision care › VISION CARE - CLIENTS TWENTY YEARS OF AGE AND YOUNGER › Section 182-544-0350 - Vision care - Covered eyeglass lenses-Clients age twenty and younger

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency covers the following plastic scratch-resistant eyeglass lenses :
(a) Single vision lenses;
(b) Round or flat top D-style
				  bifocals;
(c) Flat top trifocals;
(d) Slab-off and prism lenses
				  (including Fresnel lenses);
(e)
				  Plastic photochromatic lenses when the client's medical need is diagnosed and
				  documented as ocular albinism or retinitis pigmentosa;
(f) Polycarbonate lenses when the client's
				  medical need is diagnosed and documented as one of the following:
(i) Blind in one eye and needs protection for
				  the other eye, regardless of whether a vision correction is required;
(ii) Infants and toddlers with motor
				  ataxia;
(iii) Strabismus or
				  amblyopia;
(iv) Seizure disorder,
				  cerebral palsy, autism, attention deficit hyperactivity disorder (ADHD),
				  developmental delay, Down syndrome, bipolar, schizophrenia, or multiple
				  sclerosis.
(g) Bifocal
				  lenses to be replaced with single vision or trifocal lenses, or trifocal lenses
				  to be replaced with bifocal or single vision lenses when:
(i) The client has attempted to adjust to the
				  bifocals or trifocals for at least sixty days;
(ii) The client is unable to make the
				  adjustment; and
(iii) The trifocal
				  lenses being replaced are returned to the provider.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-544 - Vision care › VISION CARE - CLIENTS TWENTY YEARS OF AGE AND YOUNGER › Section 182-544-0400 - Vision care - Covered contact lenses-Clients age twenty and younger

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency covers contact lenses as the client's primary refractive correction
				  method when the client has a spherical correction of plus or minus 6.0 diopters
				  or greater in at least one eye. See subsection (4) of this section for
				  exceptions to the plus or minus 6.0 diopter criteria. The spherical correction
				  may be from the prescription for the glasses or the contact lenses and may be
				  written in either "minus cyl" or "plus cyl" form.
(2) The agency covers the following contact
				  lenses :
(a) Conventional soft contact lenses
				  or rigid gas permeable contact lenses that are prescribed for daily wear;
				  or
(b) Disposable contact lenses
				  that are prescribed for daily wear and have a monthly or quarterly planned
				  replacement schedule, as follows:
(i) Twelve
				  pairs of monthly replacement contact lenses; or
(ii) Four pairs of three-month replacement
				  contact lenses.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-544 - Vision care › VISION CARE - CLIENTS TWENTY YEARS OF AGE AND YOUNGER › Section 182-544-0500 - Vision care - Covered ocular prosthetics

Current through Register Vol. 24-14, July 15, 2024
See WAC
					 182-531-1000 Opthalmic
					 services.
11-14-075, recodified as §
												182-544-0500, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.08.090. 11-11-016, § 388-544-0500,
						filed 5/9/11, effective 6/9/11. Statutory Authority:
						RCW
						74.08.090,
						74.09.510,
						74.09.520. 08-14-052, §
						388-544-0500, filed 6/24/08, effective 7/25/08. Statutory Authority:
						RCW
						74.08.090,
						74.09.510,
						74.09.520 and
						42 C.F.R.
						440.120 and
						440.225. 05-13-038, §
						388-544-0500, filed 6/6/05, effective 7/7/05. Statutory Authority:
						RCW
						74.08.090,
						74.09.510 and
						74.09.520. 01-01-010, §
						388-544-0500, filed 12/6/00, effective
						1/6/01.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-544 - Vision care › VISION CARE - CLIENTS TWENTY YEARS OF AGE AND YOUNGER › Section 182-544-0550 - Vision care - Covered eye surgery

Current through Register Vol. 24-14, July 15, 2024
See WAC
					 182-531-1000 Ophthalmic
					 services.
11-14-075, recodified as §
												182-544-0550, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.08.090. 11-11-016, § 388-544-0550,
						filed 5/9/11, effective 6/9/11. Statutory Authority:
						RCW
						74.08.090,
						74.09.510,
						74.09.520. 08-14-052, §
						388-544-0550, filed 6/24/08, effective 7/25/08. Statutory Authority:
						RCW
						74.08.090,
						74.09.510,
						74.09.520 and
						42 C.F.R.
						440.120 and
						440.225. 05-13-038, §
						388-544-0550, filed 6/6/05, effective 7/7/05. Statutory Authority:
						RCW
						74.08.090,
						74.09.510 and
						74.09.520. 01-01-010, §
						388-544-0550, filed 12/6/00, effective
						1/6/01.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-544 - Vision care › VISION CARE - CLIENTS TWENTY YEARS OF AGE AND YOUNGER › Section 182-544-0560 - Vision care - Authorization

Current through Register Vol. 24-14, July 15, 2024
(1) The
				  medicaid agency requires providers to obtain authorization for covered vision
				  care services as required in this chapter.
(a) For prior authorization (PA), a provider
				  must submit a written request to the agency as specified in the agency's
				  published vision care billing instructions.
(b) For expedited prior authorization (EPA),
				  a provider must meet the clinically appropriate EPA criteria outlined in the
				  agency's published vision care billing instructions. The appropriate EPA number
				  must be used when the provider bills the agency.
(c) Upon request, a provider must provide
				  documentation to the agency showing how the client's condition met the criteria
				  for PA or EPA.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-544 - Vision care › VISION CARE - CLIENTS TWENTY YEARS OF AGE AND YOUNGER › Section 182-544-0575 - Vision care - Noncovered eyeglasses and contact lenses

Current through Register Vol. 24-14, July 15, 2024
(1) The agency does not cover the following:
(a) Executive style eyeglass
				  lenses;
(b) Bifocal contact
				  lenses;
(c) Daily and two week
				  disposable contact lenses;
(d)
				  Extended wear soft contact lenses, except when used as therapeutic contact
				  bandage lenses or for aphakic clients;
(e) Custom colored contact lenses;
(f) Glass lenses;
(g) Nonglare or anti-reflective
				  lenses;
(h) Progressive
				  lenses;
(i) Sunglasses and
				  accessories that function as sunglasses (e.g., "clip-ons");
(j) Upgrades at private expense to avoid the
				  medicaid agency's contract limitations (e.g., frames that are not available
				  through the agency's contract or noncontract frames or lenses for which the
				  client or other person pays the difference between the agency's payment and the
				  total cost).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-544 - Vision care › VISION CARE - CLIENTS TWENTY YEARS OF AGE AND YOUNGER › Section 182-544-0600 - Vision care - Payment methodology

Current through Register Vol. 24-14, July 15, 2024
(1)
				  To receive payment, vision care providers must bill the agency according to
				  this chapter, chapters 182-501 and 182-502 WAC, and the medicaid agency's
				  published billing instructions and numbered memoranda.
(2) The agency pays one hundred percent of
				  the agency contract price for covered eyeglass frames, lenses, and contact
				  lenses when these items are obtained through the agency's approved
				  contractor.
(3) See WAC
				  182-531-1850 for professional fee
				  payment methodology.
11-14-075, recodified as §
												182-544-0600, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.08.090. 11-11-014, § 388-544-0600,
						filed 5/9/11, effective 6/9/11. Statutory Authority:
						RCW
						74.08.090,
						74.09.510,
						74.09.520. 08-14-052, §
						388-544-0600, filed 6/24/08, effective 7/25/08. Statutory Authority:
						RCW
						74.08.090,
						74.09.510,
						74.09.520 and
						42 C.F.R.
						440.120 and
						440.225. 05-13-038, §
						388-544-0600, filed 6/6/05, effective 7/7/05. Statutory Authority:
						RCW
						74.08.090,
						74.09.510 and
						74.09.520. 01-01-010, §
						388-544-0600, filed 12/6/00, effective
						1/6/01.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-545 - Therapies › Section 182-545-200 - Outpatient rehabilitation (occupational therapy, physical therapy, and speech therapy)

Current through Register Vol. 24-14, July 15, 2024
(1) The following
				health professionals may enroll with the medicaid agency, as defined in WAC
				182-500-0010,
				to provide outpatient rehabilitation (which includes occupational therapy,
				physical therapy, and speech therapy) within their scope of practice to
				eligible clients:
(a) A physiatrist;
(b) A licensed occupational
				therapist;
(c) A licensed
				occupational therapy assistant (OTA) supervised by a licensed occupational
				therapist;
(d) A licensed physical
				therapist;
(e) A physical therapist
				assistant supervised by a licensed physical therapist;
(f) A licensed speech-language pathologist;
				and
(g) A licensed optometrist to
				provide vision occupational therapy only.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-545 - Therapies › Section 182-545-200 - Outpatient rehabilitation (occupational therapy, physical therapy, and speech therapy)

Current through Register Vol. 24-14, July 15, 2024
(1) The following
				health professionals may enroll with the medicaid agency, as defined in WAC
				182-500-0010, to provide
				outpatient rehabilitation (which includes occupational therapy, physical
				therapy, and speech therapy) within their scope of practice to eligible
				clients:
(a) A physiatrist;
(b) A licensed occupational
				therapist;
(c) A licensed
				occupational therapy assistant (OTA) supervised by a licensed occupational
				therapist;
(d) A licensed physical
				therapist;
(e) A physical therapist
				assistant supervised by a licensed physical therapist;
(f) A licensed speech-language pathologist;
				and
(g) A licensed optometrist to
				provide vision occupational therapy only.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-545 - Therapies › Section 182-545-400 - Habilitative services

Current through Register Vol. 24-14, July 15, 2024
(1) Habilita-tive
				services assist the client in partially or fully attaining, learning,
				maintaining, or improving developmental-age appropriate skills that were not
				fully acquired as a result of a congenital, genetic, or early acquired health
				condition. To the extent practical, habilitative services maximize the client's
				ability to function in the client's environment.
(2) Eligibility is limited to clients who are
				enrolled in the Washington apple health alternative benefits plan defined in
				WAC
				182-501-0060.
				Clients enrolled in an agency-contracted managed care organization (MCO) must
				arrange for habilitative services through their MCO.
(3) The following licensed health care
				professionals may enroll with the agency to provide habilitative services
				within their scope of practice to eligible clients:
(a) Physiatrists;
(b) Occupational therapists;
(c) Occupational therapy assistants
				supervised by a licensed occupational therapist;
(d) Physical therapists;
(e) Physical therapy assistants supervised by
				a licensed physical therapist;
(f)
				Speech-language pathologists who have been granted a certificate of clinical
				competence by the American Speech-Language-Hearing Association; and
(g) Speech-language pathologists who have
				completed the equivalent educational and work experience necessary for such a
				certificate.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-545 - Therapies › Section 182-545-900 - Neurodevelopmental centers

Current through Register Vol. 24-14, July 15, 2024
(1) This section
				describes:
(a) Neurodevelopmental centers
				that may be reimbursed by the agency;
(b) Clients who may receive covered services
				at a neurodevelopmental center; and
(c) Covered services for which a
				neurodevelopmental center may be reimbursed.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-546 - Transportation services › Section 182-546-0050 - Ambulance transportation-General

Current through Register Vol. 24-14, July 15, 2024
See WAC
				  182-546-0100
				  through 182-546-4300 for ambulance transportation and WAC
				  182-546-5000
				  through
				  182-546-6200
				  for brokered/nonemergency transportation.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-546 - Transportation services › Section 182-546-0100 - Ambulance transportation-Program

Current through Register Vol. 24-14, July 15, 2024
(1)
				The provisions of this chapter take precedence with respect to ambulance
				services in cases of ambiguity in, or conflict with, other agency rules
				governing eligibility for health care services.
(2) The medicaid agency covers emergency and
				nonemergency ambulance transportation to and from a covered health care
				service, subject to the limitations and requirements in this chapter.
11-14-075, recodified as §
											182-546-0100, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.04.057,
					 74.08.090, and
					 74.09.510. 04-17-118, §
					 388-546-0100, filed 8/17/04, effective 9/17/04. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500,
					 74.04.050,
					 74.04.055, and
					 74.04.057. 01-03-084, §
					 388-546-0100, filed 1/16/01, effective
					 2/16/01.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-546 - Transportation services › Section 182-546-0150 - Ambulance transportation- Client eligibility

Current through Register Vol. 24-14, July 15, 2024
(1) Clients are eligible for ambulance
				transportation to covered services subject to the requirements and limitations
				in this chapter.
(a) Clients in the following
				programs are eligible for ambulance services within Washington state or
				bordering cities only, as designated in WAC
				182-501-0175:
(i) Medical care services (MCS) as described
				in WAC
				182-508-0005;
(ii) Alien emergency medical (AEM) services
				as described in WAC
				182-507-0115.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-546 - Transportation services › Section 182-546-0200 - Ambulance transportation- Scope of coverage

Current through Register Vol. 24-14, July 15, 2024
(1) The ambulance program is a medical
				transportation service. The medicaid agency pays for ambulance transportation
				to and from covered medical services when the transportation is:
(a) Within the scope of an eligible client's
				medical care program (see WAC
				182-501-0060
				);
(b) Medically necessary as
				defined in WAC
				182-500-0070 based
				on the client's condition at the time of the ambulance trip and as documented
				in the client's record;
(c)
				Appropriate to the client's actual medical need; and
(d) To one of the following destinations:
(i) The closest and most appropriate
				agency-contracted medical provider of agency-covered services; or
(ii) The designated trauma facility as
				identified in the emergency medical services and trauma regional patient care
				procedures manual.