reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › INFORMAL DISPUTE RESOLUTION PROCESS › Section 182-502-0050 - Provider dispute of an agency action

Current through Register Vol. 24-14, July 15, 2024
The process described in this section applies only when
					 department rules allow a provider to dispute a department decision under this
					 section.
(1) In order for the
				  department to review a decision previously made by the department, a provider
				  must submit the request to review the decision:
(a) Within twenty-eight calendar days of the
				  date on the department's decision notice;
(b) To the address listed in the decision
				  notice; and
(c) In a manner that
				  provides proof of receipt.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › REAPPLYING FOR PARTICIPATION › Section 182-502-0060 - Reapplying for participation

Current through Register Vol. 24-14, July 15, 2024
A provider who is terminated solely under WAC
					 182-502-0030(3)
					 is eligible for immediate reapplication with the medicaid agency if the
					 provider is not a full or partial owner of a terminated group
					 practice.
WSR 11-14-075, recodified as §
												182-502-0060, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.08.090,
						74.09.080, and
						74.09.290. WSR 11-11-017, §
						388-502-0060, filed 5/9/11, effective
						6/9/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › PAYMENT › Section 182-502-0100 - General conditions of payment

Current through Register Vol. 24-14, July 15, 2024
(1) The medic-aid
				  agency reimburses for medical services furnished to an eligible client when all
				  the following apply:
(a) The service is within
				  the scope of care of the client's Washington apple health program;
(b) The service is medically
				  necessary;
(c) The service is
				  properly authorized;
(d) The
				  provider bills within the time frame set in WAC
				  182-502-0150;
(e) The provider bills according to agency
				  rules and billing instructions; and
(f) The provider follows third-party payment
				  procedures.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › PAYMENT › Section 182-502-0110 - Conditions of payment and prior authorization requirements-Medicare coinsurance, copayments, and deductibles

Current through Register Vol. 24-14, July 15, 2024
(1) The following
				  people are eligible for benefits under this section:
(a) Dual-eligible clients enrolled in
				  categorically needy Washington apple health programs;
(b) Dual-eligible clients enrolled in
				  medically needy Washington apple health programs; or
(c) Clients enrolled in the qualified
				  medicare beneficiary (QMB) program.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › PAYMENT › Section 182-502-0120 - Payment for health care services provided outside the state of Washington

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency pays for health care services provided outside the state of Washington
				  only when the service meets the provisions described in WAC
				  182-501-0180,
				  182-501-0182,
				  182-501-0184, and specific
				  program WAC.
(2) With the exception
				  of hospital services and nursing facilities, the agency pays the provider of
				  service in designated bordering cities as if the care was provided within the
				  state of Washington (see WAC
				  182-501-0175 ).
(3) With the exception of designated
				  bordering cities, the agency does not pay for health care services provided to
				  clients in medical care services (MCS) programs outside the state of Washington
				  .
(4) With the exception of
				  hospital services (see subsection (5) of this section), the agency pays for
				  health care services provided outside the state of Washington at the lower of:
(a) The billed amount; or
(b) The rate established by the Washington
				  apple health programs.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › INTEREST PENALTIES › Section 182-502-0130 - Interest penalties-Providers

Current through Register Vol. 24-14, July 15, 2024
(1)
				  Providers who are enrolled as contractors with the medicaid agency's medical
				  care programs may be assessed interest on excess benefits or other
				  inappropriate payments. Nursing home providers are governed by WAC
				  388-96-310 and are not subject to
				  this section.
(2) The agency
				  assesses interest when:
(a) The excess
				  benefits or other inappropriate payments were not the result of agency error;
				  and
(b) A provider is found liable
				  for receipt of excess benefits or other payments under
				  RCW
				  74.09.220; or
(c) A provider is notified by the agency that
				  repayment of excess benefits or other payments is due under
				  RCW
				  74.09.220.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › TIME LIMITS FOR BILLING › Section 182-502-0150 - Time limits for providers to bill the agency

Current through Register Vol. 24-14, July 15, 2024
Providers must bill the medicaid agency for covered
					 services provided to eligible clients as follows:
(1) The agency requires providers to submit
				  initial claims and adjust prior claims in a timely manner. The agency has three
				  timeliness standards:
(a) For initial claims,
				  see subsections (3), (4), (5), and (6) of this section;
(b) For resubmitted claims other than
				  prescription drug claims and claims for major trauma services, see subsections
				  (7) and (8) of this section;
(c)
				  For resubmitted prescription drug claims, see subsections (9) and (10) of this
				  section; and
(d) For resubmitting
				  claims for major trauma services, see subsection (11) of this
				  section.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › BILLING A CLIENT › Section 182-502-0160 - Billing a client

Current through Register Vol. 24-14, July 15, 2024
(1) The purpose of
				  this section is to specify the limited circumstances in which:
(a) Fee-for-service or managed care clients
				  can choose to self-pay for medical assistance services; and
(b) Providers (as defined in WAC
				  182-500-0085
				  ) have the authority to bill fee-for-service or managed care clients for
				  medical assistance services furnished to those clients.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › PROVIDER REPORTS › Section 182-502-0210 - Statistical data-provider reports

Current through Register Vol. 24-14, July 15, 2024
(1)
				  At the request of the medicaid agency, all providers enrolled with agency
				  programs must submit full reports, as specified by the agency, of goods and
				  services furnished to eligible Washington apple health clients. The agency
				  furnishes the provider with a standardized format to report these
				  data.
(2) The agency analyzes the
				  data collected from the providers' reports to secure statistics on costs of
				  goods and services furnished and makes a report of the analysis available to
				  the agency's advisory committee, the state welfare medical care committee,
				  representative organizations of provider groups enrolled with the agency, and
				  any other interested organizations or individuals.
11-14-075, recodified as §
												182-502-0210, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.08.090. 10-19-057, § 388-502-0210,
						filed 9/14/10, effective 10/15/10. Statutory Authority:
						RCW
						74.08.090,
						74.09.035. 00-15-049, §
						388-502-0210, filed 7/17/00, effective 8/17/00. Statutory Authority:
						RCW
						74.08.090. 94-10-065 (Order 3732), §
						388-502-0210, filed 5/3/94, effective 6/3/94. Formerly WAC
						388-81-020.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › APPEAL-RATE REIMBURSEMENT › Section 182-502-0220 - Administrative appeal contractor or provider rate reimbursement

Current through Register Vol. 24-14, July 15, 2024
(1) Any enrolled
				  contractor or provider of medical services has a right to an administrative
				  appeal when the contractor or provider disagrees with the medicaid agency
				  reimbursement rate. The exception to this is nursing facilities governed by WAC
				  388-96-904.
(2) The first level of appeal. A contractor
				  or provider who wants to contest a reimbursement rate must file a written
				  appeal with the agency.
(a) The appeal must
				  include the following:
(i) A statement of the
				  specific issue being appealed;
(ii)
				  Supporting documentation; and
(iii)
				  A request for the agency to recalculate the rate.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › PROVIDER PAYMENT REVIEWS AND DISPUTE RIGHTS › Section 182-502-0230 - Provider overpayment disputes-General

Current through Register Vol. 24-14, July 15, 2024
(1) This section applies to provider
				  overpayment disputes with providers who furnish health care services to
				  Washington apple health clients, except those overpayment disputes to which
				  chapter 182-502A WAC applies. For the purposes of this section:
(a) "Agency" means the health care authority
				  and its designees.
(b) "Provider"
				  has the same meaning as vendor in
				  RCW
				  41.05A.010(5).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › PROVIDER PAYMENT REVIEWS AND DISPUTE RIGHTS › Section 182-502-0260 - Appeals and dispute resolution for providers with contracts other than core provider agreements

Current through Register Vol. 24-14, July 15, 2024
(1) Providers of
				  medical services who have a contract, other than a core provider agreement,
				  with a dispute resolution provision must follow the dispute resolution process
				  described in the contract.
(2) See
				  WAC 182-502-0220 for disputes
				  involving rates. See chapter 182-502A WAC for disputes involving audits. See
				  WAC 182-502-0230 for disputes
				  involving provider reviews and termination.
11-14-075, recodified as §
												182-502-0260, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.08.090,
						74.09.290. 00-22-016, §
						388-502-0260, filed 10/20/00, effective
						11/20/00.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › PROVIDER PAYMENT REVIEWS AND DISPUTE RIGHTS › Section 182-502-0270 - Review of agency's provider dispute decision

Current through Register Vol. 24-14, July 15, 2024
(1) This section applies only when department
				  rules allow review of a department dispute decision under this section. The
				  deputy assistant secretary of the health and recovery services administration
				  (HRSA) or designee conducts the review.
(2) Providers and former providers may
				  request a review of a department dispute decision. The request must be in
				  writing and sent to: HRSA, Attn: Deputy Assistant Secretary, PO Box 45504,
				  Olympia, WA 98504-5504. The department must receive the written dispute review
				  request within twenty-eight calendar days of the date on the department's
				  written dispute decision.
(3) When
				  the department receives a timely dispute review request, the deputy or designee
				  may schedule a dispute review conference. "Dispute review conference" means an
				  informal conference for the purpose of resolving disagreements between the
				  department and a provider or former provider who is dissatisfied with a
				  department decision. The dispute review conference is not governed by the
				  Administrative Procedure Act,
				  chapter
				  34.05 RCW. If the deputy
				  or designee chooses to schedule a dispute review conference, the deputy or
				  designee will conduct the conference within ninety calendar days of the dispute
				  review request unless the deputy or designee and the party requesting review
				  agree to an extension.
(4) The
				  deputy or designee will issue a dispute review decision to the provider or
				  former provider requesting review within thirty calendar days of receiving the
				  dispute review request or within thirty calendar days of the dispute review
				  conference, whichever is later, unless both parties agree to an
				  extension.
(5) The deputy review is
				  the final level of department review for disputes to which this section
				  applies.
WSR 11-14-075, recodified as §
												182-502-0270, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.08.090. WSR 08-12-012, §
						388-502-0270, filed 5/27/08, effective
						6/27/08.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0100

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-502A-0100, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.09.200 and
					 74.08.090. 07-10-022, §
					 388-502A-0100, filed 4/23/07, effective
					 6/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0101 - Purpose

Current through Register Vol. 24-14, July 15, 2024
(1) Program
				integrity means a system of reasonable and consistent oversight of the medicaid
				program.
(2) The medicaid agency
				conducts program integrity activities to detect and prevent potential fraud,
				waste, and abuse. These activities include identifying improper payments and
				recovering overpayments.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0200

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-502A-0200, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090. 11-11-014, § 388-502A-0200,
					 filed 5/9/11, effective 6/9/11. Statutory Authority:
					 RCW
					 74.09.200 and
					 74.08.090. 07-10-022, §
					 388-502A-0200, filed 4/23/07, effective
					 6/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0300

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-502A-0300, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.09.200 and
					 74.08.090. 07-10-022, §
					 388-502A-0300, filed 4/23/07, effective
					 6/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0301 - Authority to conduct program integrity activities

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency conducts program integrity activities on
				  all Title XIX, Title XXI, and state-only-funded expenditures. See 42 C.F.R.
				  2.54, 431, 433, 438, 447, 455, 456, 457, 495, and 1001; 45 C.F.R. 92;
				  42 U.S.C.
				  1396a; and chapters 41.05, 41.05A, and 74.09
				  RCW.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0400

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-502A-0400, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.09.200 and
					 74.08.090. 07-10-022, §
					 388-502A-0400, filed 4/23/07, effective
					 6/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0401 - Program integrity activities

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency verifies entities' compliance with
				  applicable laws, rules, regulations, and agreements through program integrity
				  activities.
(1)
Methods.
Program integrity activity methods include, but are not limited to:
(a) Data mining to identify possible fraud,
				waste, and abuse (FWA) for further examination;
(b) Audits and reviews to determine
				compliance with federal, state, and agency rules and regulations, or to
				identify FWA;
(c) Investigations of
				suspected fraud and abuse;
(d)
				Algorithms to identify payment, program, and system irregularities leading to
				improper payments;
(e) On-site
				reviews and inspections of an entity's premises to ensure compliance with
				federal, state, and agency rules and regulations;
(f) Referral of enforcement actions against
				entities that have committed fraud or abuse to law enforcement agencies, or
				licensing agencies, or both;
(g)
				Technical assistance and education to prevent and identify potential
				FWA;
(h) Outreach to and education
				for entities and client communities, including how to report suspected fraud,
				explaining federal, state, and agency rules and requirements, conducting entity
				self-audits and implementing compliance programs; and
(i) Initiating and reviewing entity
				self-audits under WAC
				182-502A-0501.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0500

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-502A-0500, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.09.200 and
					 74.08.090. 07-10-022, §
					 388-502A-0500, filed 4/23/07, effective
					 6/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0501 - Entity self-audits

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency may require an entity to self-audit.
(a) The agency gives written notice of the
				instruction to self-audit.
(b) The
				entity must acknowledge receipt of the notice within thirty calendar days of
				receiving it.
(c) The entity must
				comply with all terms included in the notice; failure to timely comply with the
				notice constitutes failure to comply with a program integrity
				activity.
(d) The agency does not
				require an entity to self-audit any services or encounters that are included in
				an active state or federal program integrity activity, rate adjustment, cost
				settlement, or other payment adjustment.
(e) The agency reviews the self-audit and
				states in writing whether it accepts or rejects the results of the self-audit.
				If the agency rejects the results it may:
(i)
				Instruct the entity to repeat the self-audit; or
(ii) Audit the entity.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0600

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-502A-0600, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.09.200 and
					 74.08.090. 07-10-022, §
					 388-502A-0600, filed 4/23/07, effective
					 6/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0601 - Extrapolation

Current through Register Vol. 24-14, July 15, 2024
(1) To determine an
				improper payment from a sample, the medicaid agency may extrapolate to the
				universe from which the sample was drawn:
(a)
				If the audit identifies a sustained high level of payment error involving the
				provider; or
(b) When the agency
				has documented educational intervention to the provider and the education has
				failed to correct the provider's level of payment error.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0700

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-502A-0700, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.09.200 and
					 74.08.090. 07-10-022, §
					 388-502A-0700, filed 4/23/07, effective
					 6/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0701 - Agency outcomes

Current through Register Vol. 24-14, July 15, 2024
(1) Following the
				medicaid agency's evaluation of an entity's records including, but not limited
				to, claims, encounter data, or payments, the agency may do any combination of
				the following:
(a) Deny a claim or claim
				line.
(b) Recover an improperly
				paid claim.
(c) Instruct the entity
				to submit:
(i) Additional documentation;
				or
(ii) A new claim. If the entity
				fails to submit a new claim within sixty calendar days, the agency denies the
				new claim as untimely.
(d) Request a refund of an improper payment
				to the agency by check.
(e) Refer
				an overpayment to the office of financial recovery for collection.
(f) Issue a preliminary finding, which the
				entity may dispute under WAC
				182-502A-0801.
(i) If an entity agrees with the preliminary
				finding before the deadline stated in the notice, the entity must notify the
				agency in writing. The agency then issues a final notice.
(ii) If an entity does not respond by the
				agency's deadline, the agency issues a final notice.
(g) Issue an overpayment notice or final
				notice, which the entity may appeal under WAC
				182-502A-0901.
(i) The final notice includes:
(A) The asserted overpayment or improper
				payment amount;
(B) The reason for
				an adverse determination;
(C) The
				specific criteria and citation of legal authority used to make the adverse
				determination;
(D) An explanation
				of the entity's appeal rights;
(E)
				The appropriate procedure to submit a claims adjustment, if applicable;
				and
(F) One or more of the
				following:
(I) Directives;
(II) Educational intervention; or
(III) A program integrity compliance
				plan.
(ii) Upon
				request, the agency allows an entity with an adverse determination the option
				of repaying the amount owed according to a negotiated repayment plan of up to
				twelve months. Interest may be calculated and charged on the remaining balance
				each month.
(h) Recover
				interest under
				RCW
				41.05A.220.
(i) Impose civil penalties under
				RCW
				74.09.210.
(j) Refer the entity to appropriate licensing
				authorities for disciplinary action.
(k) Refer the entity to the agency's medical
				dental advisory committee for review and potential termination of the contract
				or core provider agreement.
(l)
				Determine it has sufficient evidence to make a credible allegation of fraud.
				The agency then:
(i) Refers the case to the
				medicaid fraud control division and any other appropriate prosecuting authority
				for further action; and
(ii)
				Suspends some or all Washington apple health payments to the entity unless the
				agency determines there is good cause not to suspend payments under
				42 C.F.R.
				455.23.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0800

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-502A-0800, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.09.200 and
					 74.08.090. 07-10-022, §
					 388-502A-0800, filed 4/23/07, effective
					 6/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0801 - Dispute resolution process

Current through Register Vol. 24-14, July 15, 2024
(1)
				An entity may informally dispute a preliminary finding. The medicaid agency
				must receive any request for dispute resolution within thirty calendar days of
				the date the entity received the preliminary finding. The request for dispute
				resolution must be in writing and include the following:
(a) The supporting evidence for each disputed
				preliminary finding; and
(b) The
				relief sought for each disputed preliminary finding.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0900

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-502A-0900, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.09.200 and
					 74.08.090. 07-10-022, §
					 388-502A-0900, filed 4/23/07, effective
					 6/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-0901 - Administrative hearing (formal appeal) right

Current through Register Vol. 24-14, July 15, 2024
(1) An entity has a right to an
				administrative hearing (formal appeal), and any resulting appeals process under
				RCW
				41.05A.170 and chapter 182-526 WAC, if the
				agency assesses an overpayment against the entity.
(2) An entity does not have an administrative
				hearing right for the denial of payment of a claim.
(3) At the administrative hearing and on
				appeal, the entity bears the burden of proving by a preponderance of the
				evidence that it has complied with applicable laws, rules, regulations, and
				agreements.
(4) The administrative
				hearing process is governed by chapter 34.05 RCW and chapter 182-526
				WAC.
(5) The medicaid agency does
				not recoup overpayments until a decision in the administrative hearing is
				issued and all appeals, if any, have been exhausted.
(6) Interest on overpayments continues to
				accrue, but it is not collected until a decision in the administrative hearing
				is issued and all appeals, if any, have been exhausted. See
				RCW
				74.09.220.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-1000

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-502A-1000, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.09.200 and
					 74.08.090. 07-10-022, §
					 388-502A-1000, filed 4/23/07, effective
					 6/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-1001 - Metrics

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency annually, compiles and publishes metrics for any contractor that
				conducts audits on the agency's behalf under
				RCW
				74.09.195(2)(b).
(2) The agency may publish metrics of the
				program integrity activities it conducts. Metrics include, but are not limited
				to:
(a) Adverse determinations;
(b) Identified improper payments;
(c) Cost avoidance;
(d) Payments; and
(e) Recoveries.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-1100

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-502A-1100, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.09.200 and
					 74.08.090. 07-10-022, §
					 388-502A-1100, filed 4/23/07, effective
					 6/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-1101 - Managed care organizations

Current through Register Vol. 24-14, July 15, 2024
This section applies to entities that contract with the
				  medicaid agency to provide services in exchange for a capitated rate.
(1) Managed care organizations (MCOs) must
				comply with and enforce all applicable program integrity:
(a) Federal and state laws and
				regulations;
(b) Terms of their
				contracts with the agency; and
(c)
				Terms of their contracts with subcontractors and providers.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-1200

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-502A-1200, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.09.200 and
					 74.08.090. 07-10-022, §
					 388-502A-1200, filed 4/23/07, effective
					 6/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502A - Program integrity › Section 182-502A-1300

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-502A-1300, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.09.200 and
					 74.08.090. 07-10-022, §
					 388-502A-1300, filed 4/23/07, effective
					 6/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-503 - Persons eligible for medical assistance › Section 182-503-0001 - Insurance affordability programs-Overview

Current through Register Vol. 24-14, July 15, 2024
(1) For the purposes of this chapter, "we" or
				"us" refers to the agency or its designee and "you" refers to the applicant
				for, or recipient of, health care coverage.
(2) A person may apply for all of the
				insurance afford-ability programs offered through the health care authority
				(HCA) or the Washington Healthplanfinder (as defined in WAC
				182-500-0015 ):
(a) Washington apple health (WAH) programs
				(defined in WAC
				182-500-0120 ). WAH includes
				medicaid programs (defined in WAC
				182-500-0070 ), the children's
				health insurance program (CHIP) (defined in WAC
				182-500-0020 ), and state-only
				funded health care programs. These programs are provided free or at low cost on
				a sliding scale to eligible persons based on their income. WAH program
				regulations for the application process and eligibility determination are found
				in chapters 182-503 through 182-527 WAC.
(b) Health insurance premium tax credits
				(defined in WAC
				182-500-0045 ). This federal
				refundable tax credit partially offsets the cost of monthly premiums for
				qualified health plan (QHP) (defined in WAC
				182-500-0090 ) insurance that an
				eligible person purchases through the Washington Healthplanfinder. Any advance
				payments of the tax credit are reconciled annually by the Internal Revenue
				Service (IRS) when the person files his or her federal tax return.
(c) Cost-sharing reductions. Cost-sharing
				reductions (defined in WAC
				182-500-0020 ) are available to
				eligible persons enrolled in a silver-level QHP and to American Indians/ Alaska
				Natives enrolled in any QHP.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-503 - Persons eligible for medical assistance › Section 182-503-0005 - Washington apple health-How to apply

Current through Register Vol. 24-14, July 15, 2024
(1) You may apply
				for Washington apple health at any time.
(2) For apple health programs for children,
				pregnant people, parents and caretaker relatives, and adults age 64 and under
				without medicare (including people who have a disability or are blind), you may
				apply:
(a) Online via the Washington
				Healthplanfinder at
www.wahealthplanfinder.org
;
(b) By calling the Washington
				Healthplanfinder customer support center and completing an application by
				telephone;
(c) By completing the
				application for health care coverage (HCA 18-001P), and mailing or faxing to
				Washington Healthplanfinder; or
(d)
				At a department of social and health services (DSHS) community services office
				(CSO).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-503 - Persons eligible for medical assistance › Section 182-503-0010 - Washington apple health-Who may apply

Current through Register Vol. 24-14, July 15, 2024
(1) You may apply for Washington apple health
				for yourself.
(2) You may apply for
				apple health for another person if you are:
(a) A legal guardian;
(b) An authorized representative (as
				described in WAC
				182-503-0130
				);
(c) A parent or caretaker
				relative of a child age eighteen or younger;
(d) A tax filer applying for a tax dependent
				;
(e) A spouse; or
(f) A person applying for someone who is
				unable to apply on their own due to a medical condition and who is in need of
				long-term care services.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-503 - Persons eligible for medical assistance › Section 182-503-0040 - Washington apple health - Interview requirements

Current through Register Vol. 24-14, July 15, 2024
(1) An individual applying for Washington
				apple health (WAH) (as defined in WAC
				182-500-0120 ) is not required to
				have an in-person interview to determine eligibility.
(2) The agency or its designee may contact an
				individual by phone or in writing to gather any additional information that is
				needed to make an eligibility determination.
(3) A phone or in-person interview is
				required to determine initial financial eligibility for WAH long-term care
				services.
(4) The interview
				requirement described in subsection (3) of this section may be waived if the
				applicant is unable to comply:
(a) Due to his
				or her medical condition; or
(b)
				Because the applicant does not have a family member or another individual that
				is able to conduct the interview on his or her behalf.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-503 - Persons eligible for medical assistance › Section 182-503-0050 - Verification of eligibility factors

Current through Register Vol. 24-14, July 15, 2024
(1)
General rules.
(a) We may verify
				the information we use to determine, redetermine, or terminate your apple
				health eligibility.
(b) We verify
				the eligibility factors listed in WAC
				182-503-0505(3).
(c) Before we ask you to provide records to
				verify an eligibility factor, we use information available from state
				databases, including data from the department of social and health services and
				the department of employment security, federal databases, or commercially
				available databases to verify the eligibility factor.
(d) We may require information from third
				parties, such as employers, landlords, and insurance companies, to verify an
				eligibility factor if the information we received:
(i) Cannot be verified through available data
				sources;
(ii) Did not verify an
				eligibility factor; or
(iii) Is
				contradictory, confusing, or outdated.
(e) We do not require you to submit a record
				unless it is necessary to determine or redetermine your eligibility.
(f) If you can obtain verification within
				three business days and we determine the verification is sufficient to confirm
				an eligibility factor, we base our initial eligibility decision upon that
				record.
(g) If we are unable to
				verify eligibility as described in (f) of this subsection, then we may consider
				third-party sources.
(h) If a fee
				is required to obtain a necessary record, we pay the fee directly to the holder
				of the record.
(i) We do not deny
				or delay your application if you failed to provide information to verify an
				eligibility factor in a particular type or form.
(j) Except for eligibility factors listed in
				WAC
				182-503-0505(3)(c)
				and (d), we accept alternative forms of
				verification. If you give us a reasonable explanation that confirms your
				eligibility, we may not require additional documentation.
(k) Once we verify an eligibility factor that
				will not change, we may not require additional verification. Examples include:
(i) U.S. citizenship;
(ii) Family relationships by birth;
(iii) Social Security numbers; and
(iv) Dates of birth, death, marriage,
				dissolution of marriage, or legal separation.
(l) If we cannot verify your immigration
				status and you are otherwise eligible for Washington apple health, we approve
				coverage and give additional time as needed to verify your immigration
				status.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-503 - Persons eligible for medical assistance › Section 182-503-0055 - Asset verification system

Current through Register Vol. 24-14, July 15, 2024
(1)
				This rule implements the asset verification system (AVS) outlined in section
				1940 of the Social Security Act.
(2) This rule applies to any client, or those
				financially responsible for them, who is subject to:
(a) The disclosure of resources, as defined
				in WAC
				182-512-0200,
				to determine eligibility; or
(b)
				Provisions related to the transfer of assets, as described in WAC
				182-513-1363.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-503 - Persons eligible for medical assistance › Section 182-503-0060 - Washington apple health Application processing times

Current through Register Vol. 24-14, July 15, 2024
(1) We process applications for Washington
				apple health (medicaid) within forty-five calendar days, with the following
				exceptions:
(a) If you are pregnant, we
				process your application within fifteen calendar days;
(b) If you are applying for a program that
				requires a disability decision, we process your application within sixty
				calendar days; or
(c) The modified
				adjusted gross income (MAGI)-based apple health application process using
				Washington Healthplanfinder may provide faster or real-time determination of
				eligibility for medicaid.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-503 - Persons eligible for medical assistance › Section 182-503-0070 - Washington apple health (WAH)-When coverage begins

Current through Register Vol. 24-14, July 15, 2024
(1) Your Washington apple health (WAH)
				coverage starts on the first day of the month you applied for and we decided
				you are eligible to receive coverage, unless one of the exceptions in
				subsection (4) of this section applies to you.
(2) Sometimes we can start your coverage up
				to three months before the month you applied (see WAC
				182-504-0005 ).
(3) If you are confined or incarcerated as
				described in WAC
				182-503-0010, your coverage
				cannot start before the day you are discharged, except when:
(a) You are hospitalized during your
				confinement; and
(b) The hospital
				requires you to stay overnight.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-503 - Persons eligible for medical assistance › Section 182-503-0080 - Washington apple health- Application denials and withdrawals

Current through Register Vol. 24-14, July 15, 2024
(1) We follow the
				rules about notices and letters in chapter 182-518 WAC. We follow the rules
				about timelines in WAC
				182-503-0060.
(2) We deny your application for apple health
				coverage when:
(a) You tell us either orally
				or in writing to withdraw your request for coverage; or
(b) Based on all information we have received
				from you and other sources within the time frames stated in WAC
				182-503-0060,
				including any extra time given at your request or to accommodate a disability
				or limited-English proficiency:
(i) We are
				unable to determine that you are eligible; or
(ii) We determine that you are not
				eligible.
(c) You are
				subject to asset verification and do not provide authorization as described in
				WAC 182-503-0055.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-503 - Persons eligible for medical assistance › Section 182-503-0090 - Washington apple health-Exceptions to rule

Current through Register Vol. 24-14, July 15, 2024
(1) A client or client's representative may
				request an exception to a Washington apple health financial eligibility rule in
				Title 182 WAC. The request for an exception to rule (ETR) may be submitted
				orally or in writing. The request must:
(a) Be
				received within ninety calendar days of the agency action with which the client
				disagrees or wants waived;
(b)
				Identify the rule for which an exception is being requested;
(c) State what the client is requesting;
				and
(d) Describe how the request
				meets subsection (2) of this section.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-503 - Persons eligible for medical assistance › Section 182-503-0100 - Washington apple healthRights and responsibilities

Current through Register Vol. 24-14, July 15, 2024
For the purposes of this chapter, "we" refers to the agency
				  or its designee and "you" refers to the applicant for, or recipient of, health
				  care coverage.
(1) If you are applying
				for or receiving health care coverage, you have the right to:
(a) Have your rights and responsibilities
				explained to you and given in writing;
(b) Be treated politely and fairly without
				regard to your race, color, political beliefs, national origin, religion, age,
				gender (including gender identity and sex stereotyping), sexual orientation,
				disability, honorably discharged veteran or military status, or
				birthplace;
(c) Ask for health care
				coverage using any method listed under WAC
				182-503-0010 (if you ask us for a
				receipt or confirmation, we will provide one to you);
(d) Get help completing your application if
				you ask for it;
(e) Have an
				application processed promptly and no later than the timelines described in WAC
				182-503-0060;
(f) Have at least ten calendar days to give
				the agency or its designee information needed to determine eligibility and be
				given more time if asked for;
(g)
				Have personal information kept confidential; we may share information with
				other state and federal agencies for purposes of eligibility and enrollment in
				Washington apple health;
(h) Get
				written notice, in most cases, at least ten calendar days before the agency or
				its designee denies, terminates, or changes coverage;
(i) Ask for an appeal if you disagree with a
				decision we make. You can also ask a supervisor or administrator to review our
				decision or action without affecting your right to a fair hearing;
(j) Ask for and get interpreter or translator
				services at no cost and without delay;
(k) Ask for voter registration assistance;
(l) Refuse to speak to an
				investigator if we audit your case. You do not have to let an investigator into
				your home. You may ask the investigator to come back at another time. Such a
				request will not affect your eligibility for health care coverage;
(m) Get equal access services under WAC
				182-503-0120 if you are
				eligible;
(n) Ask for support
				enforcement services through the division of child support; and
(o) Refuse to cooperate with us in
				identifying, using, or collecting third-party benefits (such as medical
				support) if you fear, and can verify, that your cooperating with us could
				result in serious physical or emotional harm to you, your children, or a child
				in your care. Verification may include one of the following:
(i) A statement you sign, outlining your
				fears and concerns;
(ii) Civil or
				criminal court orders (such as domestic violence protection orders, restraining
				orders, and no-contact orders);
(iii) Medical, police, or court reports;
				or
(iv) Written statement from
				clergy, friends, relatives, neighbors, or co-workers.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-503 - Persons eligible for medical assistance › Section 182-503-0110 - Washington apple healthLimited-English proficient (LEP) services

Current through Register Vol. 24-14, July 15, 2024
(1) We provide
				interpreter and translation services (limited-English proficient or LEP
				services) free of charge to you if you have limited ability to read, write,
				and/or speak English. Interpreter services are those used for oral
				communication between two parties who do not speak the same language.
				Translation services are those used for written communication.
(2) We provide LEP services in your primary
				language.
(a) A primary language is the
				language you tell us that you wish to use when communicating with us. You may
				designate at least one primary language for oral communications and at least
				one primary language for written communications, and you may designate a
				different primary language for oral and for written communications.
(b) We note your primary languages in a
				record available to the agency, its designee, and health benefit exchange
				employees.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-503 - Persons eligible for medical assistance › Section 182-503-0120 - Washington apple healthEqual access services

Current through Register Vol. 24-14, July 15, 2024
(1) When you have a mental, neurological,
				cognitive, physical or sensory impairment, or limitation that prevents you from
				receiving health care coverage, we provide services to help you apply for,
				maintain, and understand the health care coverage options available and
				eligibility decisions we make. These services are called equal access (EA)
				services.
(2) We provide EA
				services on an ongoing basis to ensure that you are able to maintain health
				care coverage and access to services we provide. EA services include, but are
				not limited to:
(a) Helping you to:
(i) Apply for or renew coverage;
(ii) Complete and submit forms;
(iii) Give us information to determine or
				continue your eligibility;
(iv) Ask
				for continued coverage;
(v) Ask for
				reinstated (restarted) coverage after your coverage ends; and
(vi) Ask for and participate in a
				hearing.