reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0650 - Hospital physician-related services not requiring authorization when provided in agency-approved centers of excellence or hospitals authorized to provide the specific services

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency covers the following services without
				  prior authorization when provided in agency-approved centers of excellence. The
				  agency issues periodic publications listing centers of excellence. These
				  services include the following:
(1)
				All transplant procedures specified in WAC
				182-550-1900;
(2) Chronic pain management services,
				including outpatient evaluation and inpatient treatment, as described under WAC
				182-550-2400. See also WAC
				182-531-0700;
(3) Sleep studies including, but not limited
				to, polysomnograms for clients one year of age and older. The agency allows
				sleep studies only in outpatient hospital settings as described under WAC
				182-550-6350. See also WAC
				182-531-1500; and
(4) Diabetes education, in a DOH-approved
				facility, per WAC
				182-550-6300.
11-14-075, recodified as §
											182-531-0650, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090. 10-19-057, § 388-531-0650,
					 filed 9/14/10, effective 10/15/10. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.520. 05-12-022, §
					 388-531-0650, filed 5/20/05, effective 6/20/05; 01-01-012, § 388-531-0650,
					 filed 12/6/00, effective 1/6/01.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0700 - Inpatient chronic pain management physician-related services

Current through Register Vol. 24-14, July 15, 2024
(1) The department
				covers inpatient chronic pain management services only when the services are
				obtained through a department-approved chronic pain facility.
(2) A client qualifies for inpatient chronic
				pain management services when all of the following apply:
(a) The client has had chronic pain for at
				least three months, that has not improved with conservative treatment,
				including tests and therapies;
(b)
				At least six months have passed since a previous surgical procedure was done in
				relation to the pain problem; and
(c) Clients with active substance abuse must
				have completed a detoxification program, if appropriate, and must be free from
				drugs or alcohol for six months.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0750 - Inpatient hospital physician-related services

Current through Register Vol. 24-14, July 15, 2024
(1) The department separately reimburses the
				attending provider for inpatient hospital professional services rendered by the
				attending provider during the surgical follow-up period only if the services
				are performed for an emergency condition or a diagnosis that is unrelated to
				the inpatient stay.
(2) The
				department reimburses for only one inpatient hospital call per client, per day
				for the same or related diagnoses. If a call is included in the
global
				surgery reimbursement,
the department does not reimburse
				separately.
(3) The department
				reimburses a hospital admission related to a planned surgery through the global
				fee for surgery.
11-14-075, recodified as §
											182-531-0750, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090. 10-19-057, § 388-531-0750,
					 filed 9/14/10, effective 10/15/10. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.520. 01-01-012, §
					 388-531-0750, filed 12/6/00, effective
					 1/6/01.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0800 - Laboratory and pathology physician-related services

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency pays providers for
				laboratory services only when:
(a) The
				provider is certified according to Title XVII of the Social Security Act
				(medicare), if required; and
(b)
				The provider has a clinical laboratory improvement amendment (CLIA) certificate
				and identification number.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0850 - Laboratory and pathology physician-related services reimbursement

Current through Register Vol. 24-14, July 15, 2024
(1) The department
				pays for clinical diagnostic laboratory procedures based on the
medicare
				clinical diagnostic laboratory fee schedule (MCDLF)
for the state of
				Washington. The department obtains information used to update fee schedule
				regulations from Program Memorandum and Regional Medicare Letters as published
				by HCFA.
(2) The department updates
				budget-neutral fees each July by:
(a)
				Determining the units of service and expenditures for a base period.
				Then,
(b) Determining in total the
				ratio of current department fees to existing medicare fees. Then,
(c) Determining new department fees by
				adjusting the new medicare fee by the ratio. Then,
(d) Multiplying the units of service by the
				new department fee to obtain total estimated expenditures. Then,
(e) Comparing the expenditures in subsection
				(14)(d) of this section to the base period expenditures. Then,
(f) Adjusting the new ratio until estimated
				expenditures equals the base period amount.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0900 - Neonatal intensive care unit (NICU) physician-related services

Current through Register Vol. 24-14, July 15, 2024
(1) The department
				pays the physician directing the care of a neonate or infant in an NICU, for
				NICU services.
(2) NICU services
				include, but are not limited to, any of the following:
(a) Patient management;
(b) Monitoring and treatment of the neonate,
				including nutritional, metabolic and hematologic maintenance;
(c) Parent counseling; and
(d) Personal direct supervision by the
health care team
of activities required for diagnosis, treatment,
				and supportive care of the patient.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1000 - Ophthalmic services

Current through Register Vol. 24-14, July 15, 2024
Refer to chapter 182-544 WAC for vision-related hardware
				  coverage.
(1) The medicaid agency
				covers eye examinations, refraction and fitting services. The agency pays for
				these services without prior authorization as follows:
(a) Once every twenty-four months for
				asymptomatic clients age twenty-one and older;
(b) Once every twelve months for asymptomatic
				clients age twenty and younger; or
(c) Once every twelve months, regardless of
				age, for asymptomatic clients of the division of developmental
				disabilities.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1025

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-531-1025, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090. 11-14-055, § 388-531-1025,
					 filed 6/29/11, effective 7/30/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1050 - Manipulative therapy

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency pays for manipulative therapy only when:
(a) Provided by an osteopathic physician
				licensed under
				chapter
				18.57 RCW or naturopathic
				physicians licensed under chapter 18.36A RCW; and
(b) Billed using the appropriate CPT codes
				that involve the number of body regions involved.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1100 - Out-of-state physician services

Current through Register Vol. 24-14, July 15, 2024
(1)
				The medicaid agency covers medical services provided to eligible clients who
				are temporarily located outside the state, subject to the provisions of this
				chapter and WAC
				182-501-0180.
(2) Out-of-state border areas as described
				under WAC
				182-501-0175 are not subject to
				out-of-state limitations. The agency considers physicians in border areas as
				providers in the state of Washington.
(3) In order to be eligible for
				reimbursement, out-of-state physicians must meet all criteria for, and must
				comply with all procedures required of in-state physicians, in addition to
				other requirements of this chapter.
11-14-075, recodified as §
											182-531-1100, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090. 10-19-057, § 388-531-1100,
					 filed 9/14/10, effective 10/15/10. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.520. 01-01-012, §
					 388-531-1100, filed 12/6/00, effective
					 1/6/01.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1150 - Physician care plan oversight services

Current through Register Vol. 24-14, July 15, 2024
(1) The department covers
physician
				care plan
oversight services only when:
(a) A physician provides the service;
				and
(b) The client is served by a
				home health agency, a nursing facility, or a
hospice.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1200 - Physician office medical supplies

Current through Register Vol. 24-14, July 15, 2024
(1) Refer to the
				medicaid agency's published physician-related services/health care professional
				services billing guide for a list of:
(a)
				Supplies that are a routine part of office or other outpatient procedures and
				that cannot be billed separately; and
(b) Supplies that can be billed separately
				and that the medicaid agency considers nonroutine to office or outpatient
				procedures.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1250 - Physician standby services

Current through Register Vol. 24-14, July 15, 2024
(1) The
				department reimburses
physician standby
services only when the
				standby physician does not provide care or service to other clients during this
				period, and either:
(a) The services are
				provided in conjunction with newborn care history and examination, or result in
				an admission to a neonatal intensive care unit on the same day; or
(b) A physician requests another physician to
				stand by, resulting in the prolonged attendance by the second physician without
				face-to-face client contact.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1300 - Foot care services for clients twenty-one years of age and older

Current through Register Vol. 24-14, July 15, 2024
(1) This section
				addresses care of the lower extremities (foot and ankle) referred to as foot
				care and applies to clients twenty-one years of age and older.
(2) The department covers the foot care
				services listed in this section when those services are provided by any of the
				following health care providers and billed to the department using procedure
				codes and diagnosis codes that are within their scope of practice:
(a) Physicians or physician's
				assistants-certified (PA-C);
(b)
				Osteopathic physicians, surgeons, or physician's assistant-certified
				(PA-C);
(c) Podiatric physicians
				and surgeons; or
(d) Advanced
				registered nurse practitioners (ARNP).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1350 - Prolonged physician-related service

Current through Register Vol. 24-14, July 15, 2024
(1) The department reimburses prolonged
				services based on established medicare guidelines. The services provided may or
				may not be continuous. The services provided must meet both of the following:
(a) Consist of face-to-face contact between
				the physician and the client; and
(b) Be provided with other
				services.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1400 - Psychiatric physician-related services and other professional mental health services

Current through Register Vol. 24-14, July 15, 2024
(1) The mental
				health services covered in this section are different from the mental health
				services covered under community mental health and involuntary treatment
				programs in chapter 182-538D WAC.
(2) Inpatient and outpatient mental health
				services not covered under chapter 182-538D WAC may be covered by the agency
				under this section.
Inpatient mental health services
(3) For hospital inpatient psychiatric
				admissions, providers must comply with chapter 182-538D WAC.
(4) The agency covers professional inpatient
				mental health services as follows:
(a) When
				provided by a psychiatrist, psychiatric advanced registered nurse practitioner
				(ARNP), psychiatric mental health nurse practitioner-board certified
				(PMHNP-BC), or psychologist in conjunction with the prescribing
				provider;
(b) The agency pays only
				for the total time spent on direct psychiatric client care during each visit,
				including services provided when making rounds. The agency considers services
				provided during rounds to be direct client care services and may include, but
				are not limited to:
(i) Individual
				psychotherapy up to one hour;
(ii)
				Family/group therapy; or
(iii)
				Electroconvulsive therapy.
(c) One electroconvulsive therapy or
				narcosynthesis per client, per day, and only when performed by a
				psychiatrist.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1450 - Radiology physician-related services

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency reimburses radiology services subject to the limitations in this section
				and under WAC
				182-531-0300.
(2) The agency does not make separate
				payments for contrast material. The exception is low osmolar contrast media
				(LOCM) used in in-trathecal, intravenous, and intra-arterial injections.
				Clients receiving these injections must have one or more of the following
				conditions:
(a) A history of previous adverse
				reaction to contrast material. An adverse reaction does not include a sensation
				of heat, flushing, or a single episode of nausea or vomiting;
(b) A history of asthma or allergy;
(c) Significant cardiac dysfunction including
				recent or imminent cardiac decompensation, severe arrhythmias, unstable angina
				pectoris, recent myocardial infarction, and pulmonary hypertension;
(d) Generalized severe
				debilitation;
(e) Sickle cell
				disease;
(f) Preexisting renal
				insufficiency; and/or
(g) Other
				clinical situations where use of any media except LOCM would constitute a
				danger to the health of the client.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1500 - Sleep studies

Current through Register Vol. 24-14, July 15, 2024
(1) Purpose. For
				the purposes of this section, sleep studies include polysomnogra-phy (PSG),
				unattended home sleep test (HST), and multiple sleep latency testing (MSLT).
				The medicaid agency covers attended, full-channel, PSG, MSLT, and unattended
				HSTs when:
(a) Ordered by the client's
				physician;
(b) Performed by an
				agency-designated center of excellence (COE) that is an independent diagnostic
				testing facility, sleep laboratory, or outpatient hospital; and
(c) Results are used to:
(i) Establish a diagnosis of narcolepsy or
				sleep apnea; or
(ii) Evaluate a
				client's response to therapy, such as continuous positive airway pressure
				(CPAP).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1550 - Sterilization physician-related services

Current through Register Vol. 24-14, July 15, 2024
(1) For purposes of this section,
				sterilization is any medical procedure, treatment, or operation for the purpose
				of rendering a client permanently incapable of reproducing.
Hysterectomy results in sterilization and is not covered by
				  the medicaid agency solely for that purpose. (See WAC
				  182-531-0150
				  and
				  182-531-0200
				  for more information about hysterectomies.)
STERILIZATION
(2) The agency covers sterilization when all
				of the following apply:
(a) The client is at
				least eighteen years of age at the time an agency-approved consent form is
				signed;
(b) The client is a
				mentally competent individual;
(c)
				The client participates in a medical assistance program (see WAC
				182-501-0060
				);
(d) The client has voluntarily
				given informed consent; and
(e) The
				date the client signed a sterilization consent is at least thirty days and not
				more than one hundred eighty days before the date of the sterilization
				procedure.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1600 - Bariatric surgery

Current through Register Vol. 24-14, July 15, 2024
(1) The agency
				covers medically necessary bariatric surgery for eligible clients.
(2) Bariatric surgery must be performed in a
				hospital with a bariatric surgery program, and the hospital must be:
(a) Located in the state of Washington or
				approved border cities (see WAC
				182-501-0175 ); and
(b) Meet the requirements of WAC
				182-550-2301.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1625 - Outpatient hemophilia treatment requirements - Center of excellence

Current through Register Vol. 24-14, July 15, 2024
A hemophilia treatment center of excellence (COE) uses a
				  comprehensive care model to provide care for persons with bleeding disorders.
				  The comprehensive care model includes specialized prevention, diagnostic, and
				  treatment programs designed to provide family-centered education,
				  state-of-the-art treatment, research, and support services for individuals and
				  families living with bleeding disorders.
(1) The agency pays for hemophilia and von
				Willebrand related products for administration in the home only when provided
				through a qualified hemophilia treatment COE.
(2) To become a qualified hemophilia
				treatment COE, a hemophilia center must meet all of the following:
(a) Have a current core provider agreement in
				accordance with WAC
				182-502-0005;
(b) Be a federally approved hemophilia
				treatment center (HTC) as defined in WAC
				182-531-0050 and meet or exceed
				all Medical and Scientific Advisory Council (MASAC) standards of care and
				delivery of services;
(c)
				Participate in the public health service 340B provider drug discount program
				and be listed in the medicaid exclusion files maintained by the federal Health
				Resources and Services Administration (HRSA) Office of Pharmacy Affairs
				(OPA);
(d) Submit a written request
				to the agency to be a qualified hemophilia treatment center of excellence and
				include proof of the following:
(i) U.S.
				Center for Disease Control (CDC) and prevention surveillance site
				identification number; and
(ii)
				Listing in the hemophilia treatment center (HTC) directory.
(e) Receive written approval
				including conditions of payment and billing procedures from the
				agency.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1650 - Substance abuse detoxification physician-related services

Current through Register Vol. 24-14, July 15, 2024
(1) The department
				covers physician services for three-day alcohol detoxification or five-day drug
				detoxification services for a client eligible for medical care program services
				in a department-enrolled hospital-based detoxification center.
(2) The department covers treatment in
				programs certified under chapter 388-805 WAC or its successor.
(3) The department covers detoxification and
				medical stabilization services to chemically using pregnant (CUP) women for up
				to twenty-seven days in an inpatient hospital setting.
11-14-075, recodified as §
											182-531-1650, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090. 10-19-057, § 388-531-1650,
					 filed 9/14/10, effective 10/15/10. Statutory Authority:
					 RCW
					 74.04.050,
					 74.04.057,
					 74.08.090, and
					 Public Law
					 104-191. 03-19-081, § 388-531-1650, filed
					 9/12/03, effective 10/13/03. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.520. 01-01-012, §
					 388-531-1650, filed 12/6/00, effective
					 1/6/01.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1675 - Washington apple health-Gender affirming interventions for gender dysphoria

Current through Register Vol. 24-14, July 15, 2024
(1)
Overview
				of treatment program.
(a)
Medicaid agency coverage.
The medicaid agency covers the services
				listed in (b) of this subsection to treat gender dysphoria (also referred to as
				gender incongruence) under WAC
				182-501-0050 and
				182-531-0100. These services
				include life-changing procedures that may not be reversible.
(b)
Medical services covered.
Medical services covered by the agency include, but are not limited to:
(i) Presurgical and postsurgical hormone
				therapy;
(ii) Puberty suppression
				therapy;
(iii) Behavioral health
				services; and
(iv) Surgical and
				ancillary services including, but not limited to:
(A) Anesthesia;
(B) Labs;
(C) Pathology;
(D) Radiology;
(E) Hospitalization;
(F) Physician services; and
(G) Hospitalizations and physician services
				required to treat postoperative complications of procedures performed under
				this section.
(c)
Surgical services covered.
Surgical services to treat gender dysphoria are a covered service for clients
				who have a diagnosis of gender dysphoria made by a provider who meets the
				qualifications outlined in chapter 182-502 WAC.
(d)
Medical necessity.
Under
				this program, the agency authorizes and pays for only medically necessary
				services. Medical necessity is defined in WAC
				182-500-0070 and is determined
				under WAC
				182-501-0165 and limitation
				extensions in accordance with WAC
				182-501-0169.
(e)
Provider requirements.
Providers should be knowledgeable of gender-nonconforming identities and
				expressions, and the assessment and treatment of gender dysphoria, including
				experience utilizing standards of care that include the World Professional
				Association for Transgender Health (WPATH) Standards of Care.
(f)
Clients age twenty and
				younger.
The agency evaluates requests for clients age twenty and
				younger according to the early and periodic screening, diagnosis, and treatment
				(EPSDT) program described in chapter 182-534 WAC. Under the EPSDT program, the
				agency pays for a service if it is medically necessary, safe, effective, and
				not experimental.
(g)
Transportation services.
The agency covers transportation services
				under the provisions of chapter 182-546 WAC.
(h)
Out-of-state care.
Any
				out-of-state care, including a presurgical consultation, must be prior
				authorized as an out-of-state service under WAC
				182-501-0182.
(i)
Reversal procedures.
The
				agency does not cover procedures and surgeries related to reversal of gender
				affirming surgery.
(j)
Corrective surgeries for intersex traits.
The agency covers
				corrective or reparative surgeries for people with intersex traits who received
				surgeries that were performed without the person's consent.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1700 - Surgical physician-related services

Current through Register Vol. 24-14, July 15, 2024
(1) The agency's global surgical
				reimbursement for all covered surgeries includes all of the following:
(a) The operation itself;
(b) Postoperative dressing changes,
				including:
(i) Local incision care and removal
				of operative packs;
(ii) Removal of
				cutaneous sutures, staples, lines, wire, tubes, drains, and splints;
(iii) Insertion, irrigation, and removal of
				urinary catheters, routine peripheral intravenous lines, nasogastric and rectal
				tubes; or
(iv) Change and removal
				of tracheostomy tubes.
(c) All additional medical or surgical
				services required because of complications that do not require additional
				operating room procedures.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1710 - Alcohol and substance misuse counseling

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency covers alcohol and
				substance misuse counseling through screening, brief intervention, and referral
				to treatment (SBIRT) services when delivered by, or under the supervision of, a
				qualified licensed physician or other qualified licensed health care
				professional within the scope of their practice.
(2) SBIRT is a comprehensive, evidence-based
				public health practice designed to identify, reduce and prevent problematic
				use, abuse, and dependence on alcohol and illicit drugs. SBIRT can be used to
				identify people who are at risk for or have some level of substance use
				disorder which can lead to illness, injury, or other long-term morbidity or
				mortality. SBIRT services are provided in a wide variety of medical and
				community health care settings such as primary care centers, hospital emergency
				rooms, trauma centers, and dental offices.
(3) The following health care professionals
				are eligible to become qualified SBIRT providers to deliver SBIRT services or
				supervise qualified staff to deliver SBIRT services:
(a) Advanced registered nurse practitioners,
				in accordance with chapters 18.79 RCW and 246-840 WAC;
(b) Substance use disorder professionals
				(SUDP), in accordance with chapters 18.205 RCW and 246-811 WAC;
(c) Licensed practical nurses, in accordance
				with chapters 18.79 RCW and 246-840 WAC;
(d) Mental health counselors, in accordance
				with chapters 18.225 RCW and 246-809 WAC;
(e) Marriage and family therapists, in
				accordance with chapters 18.225 RCW and 246-809 WAC;
(f) Independent and advanced social workers,
				in accordance with chapters 18.225 RCW and 246-809 WAC;
(g) Physicians, in accordance with chapters
				18.71 RCW and 246-919 WAC;
(h)
				Physician assistants, in accordance with chapters 18.71A RCW and 246-918
				WAC;
(i) Psychologists, in
				accordance with chapters 18.83 RCW and 246-924 WAC;
(j) Registered nurses, in accordance with
				chapters 18.79 RCW and 246-840 WAC;
(k) Dentists, in accordance with chapters
				18.260 and 246-817; and
(l) Dental
				hygienists, in accordance with chapters 18.29 and 246-815 WAC.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1720 - Tobacco/nicotine cessation counseling

Current through Register Vol. 24-14, July 15, 2024
(1)
				The medicaid agency covers tobacco/nicotine cessation counseling when:
(a) Delivered by qualified providers through
				an agency-approved tobacco/nicotine cessation telephone counseling
				service;
(b) The client is pregnant
				or in the postpartum period as defined in
				42
				C.F.R. 435.170. The agency pays for
				face-to-face office visits for tobacco/nicotine cessation counseling for these
				clients with the following limits:
(i)
				Counseling must be provided by qualified physicians, advanced registered nurse
				practitioners (ARNPs), physician assistants-certified (PA-Cs), naturopathic
				physicians, pharmacists, certified nurse-midwives (CNM), licensed midwives
				(LM), psychologists, or dentists;
(ii) Two tobacco/nicotine cessation
				counseling attempts are allowed every twelve months. An attempt is defined as
				up to four tobacco/nicotine cessation counseling sessions; and
(iii) The agency does not cover more than one
				face-to-face tobacco/nicotine cessation counseling session per client, per day.
				The provider must keep written documentation in the client's record for each
				session.
(c) Provided
				through screening, brief intervention, and referral to treatment (SBIRT). To
				receive payment for tobacco/ nicotine cessation counseling through SBIRT,
				providers must bill the agency using the agency's published billing
				instructions.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1740 - Treat and refer services

Current through Register Vol. 24-14, July 15, 2024
(1) The
				purpose of treat and refer services is to reduce the number of avoidable
				emergency room transports, i.e., transports that are nonemergency or
				nonurgent.
(2) Treat and refer
				services are covered health care services for a client who has accessed 911 or
				a similar public dispatch number, and whose condition does not require
				ambulance transport to an emergency department based on the clinical
				information available at the time of service.
(3) Treat and refer services can be provided
				by any city and town fire department, fire protection district organized under
				Title 52 RCW, regional fire protection service authority organized under
				chapter 52.26 RCW, provider of emergency medical services that levy a tax under
				RCW
				84.52.069, and federally recognized Indian
				tribe.
(4) To receive payment for
				covered health care services provided to clients under this section, an entity
				that meets the criteria in subsection (3) of this section must be an enrolled
				medicaid provider with an active core provider agreement for the service period
				specified in the claim, and have an established community assistance referral
				and education services program under
				RCW
				35.21.930.
(a) Prior to billing and receiving payment,
				participating providers must submit a participation agreement and attestation
				form to the agency certifying their compliance with
				RCW
				35.21.930.
(b) Providers must immediately notify the
				agency if they no longer meet the requirements of
				RCW
				35.21.930. Providers who no longer meet the
				requirements of the program and continue to bill and receive payment under the
				program must return any overpayment under
				RCW
				41.05A.170.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1750 - Transplant coverage for physician-related services

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency covers transplants when performed in an
				  agency-approved center of excellence. See WAC
				  182-550-1900 for information
				  regarding transplant coverage.
11-14-075, recodified as §
											182-531-1750, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090. 10-19-057, § 388-531-1750,
					 filed 9/14/10, effective 10/15/10. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.520. 01-01-012, §
					 388-531-1750, filed 12/6/00, effective
					 1/6/01.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1800 - Transplant coverage - Medical criteria to receive transplants

Current through Register Vol. 24-14, July 15, 2024
See WAC 182-550-2000 for information about medical criteria
				  to receive transplants.
11-14-075, recodified as §
											182-531-1800, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.520. 01-01-012, §
					 388-531-1800, filed 12/6/00, effective
					 1/6/01.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1850 - Payment methodology for physician-related services-General and billing modifiers

Current through Register Vol. 24-14, July 15, 2024
GENERAL PAYMENT METHODOLOGY
(1) The medicaid agency bases the payment
				methodology for most physician-related services on medicare's resource-based
				relative value scale (RBRVS). The agency obtains information used to update the
				agency's RBRVS from the centers for medicare and medicaid services (CMS)
				relative value unit (RVU) file.
(2)
				The agency updates and revises the RBRVS calculations during the agency's
				annual update.
(3) The agency
				determines a budget-neutral conversion factor (CF) for each RBRVS update, by
				doing the following:
(a) First, determining
				the units of service and expenditures for a base period;
(b) Second, applying the latest medicare RVU
				obtained from the medicare physician fee schedule database (MPFSDB), as
				published in the CMS RVU file, and blended Washington (WA) geographic practice
				cost indices (GCPI) to obtain projected units of service for the new
				period;
(c) Third, multiplying the
				projected units of service by conversion factors to obtain estimated
				expenditures;
(d) Fourth, comparing
				expenditures obtained in (c) of this subsection with base period expenditure
				levels; and
(e) Fifth, adjusting
				the dollar amount for the conversion factor until the product of the conversion
				factor and the projected units of service at the new RVUs equals the base
				period amount.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-1900 - Payment-General requirements for physician-related services

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency pays physicians and
				related providers for covered services provided to eligible clients on a
				fee-for-service basis, subject to the exceptions, restrictions, and other
				limitations listed in this chapter and other published issuances.
(2) To receive payment, physicians must bill
				the agency according to the conditions of payment under WAC
				182-502-0100.
(3) The agency does not separately reimburse
				certain administrative costs or services. The agency considers these costs to
				be included in the payment. These costs and services include the following:
(a) Delinquent payment fees;
(b) Educational supplies;
(c) Mileage;
(d) Missed or canceled
				appointments;
(e) Reports, client
				charts, insurance forms, and copying expenses;
(f) Service charges;
(g) Take home drugs; and
(h) Telephoning (e.g., for prescription
				refills).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-2000 - Increased payments for physician-related services for qualified trauma cases

Current through Register Vol. 24-14, July 15, 2024
(1) The health care
				authority's physician trauma care fund (TCF) is an amount that is legislatively
				appropriated to the medicaid agency each biennium for the purpose of increasing
				the agency's payment to physicians and other clinicians (those who are
				performing services within their licensed and credentialed scope of practice)
				providing qualified trauma care services to medical assistance clients covered
				under the agency's medical assistance programs.
(2) Trauma care services provided to clients
				in:
(a) Medicaid, disability lifeline (DL),
				incapacity-based medical care services (MCS), children's health insurance
				program (CHIP), and apple health for kids, qualify for enhanced rate payments
				from the TCF. Trauma care services provided to a DL or MCS client qualify for
				enhanced rates only during the client's certification period. See WAC
				182-504-0010;
(b) The alien
				emergency medical (AEM), refugee assistance, and alien medical programs do not
				qualify for enhanced rate payments from the TCF; and
(c) The agency's managed care programs
				qualify for enhanced rate payments from the TCF, effective with dates of
				service on and after July 1, 2012.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-2010 - Enhanced reimbursementIndependent advanced registered nurse practitioners (ARNPs)

Current through Register Vol. 24-14, July 15, 2024
(1) Effective for
				dates of service July 1, 2013, through December 31, 2014, the agency is
				authorized by the legislature to increase reimbursement rates to medicare
				levels for independent ARNPs who provide qualified primary care services to
				eligible medicaid clients.
(2) For
				the purpose of this section, the following definitions apply:
(a) Independent ARNP Means a health care
				practitioner who is not supervised by an eligible primary care physician and
				not already receiving increased rates for evaluation and management services
				and vaccine administration services as provided under the Affordable Care Act,
				section 1202.
(b) Qualified primary
				care services Means evaluation and management services and vaccine
				administration services provided to eligible medicaid clients.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-2020 - Enhanced reimbursement - Long-acting reversible contraception (LARC)

Current through Register Vol. 24-14, July 15, 2024
(1) Effective for
				dates of service on or after September 1, 2015, the medicaid agency pays
				enhanced rates for physician procedure codes directly related to insertion or
				implant of long-acting reversible contraceptives (LARC).
(2) The agency pays the enhanced rate as a
				set amount above the standard resource based relative value scale (RBRVS) rate
				calculation described in WAC
				182-531-1850.
(3) The agency will pay the enhanced rate to
				all providers eligible to bill for these services.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-2030 - Enhanced rates for pediatric care services and administration of vaccines

Current through Register Vol. 24-14, July 15, 2024
(1) Subject to
				available funds, the medicaid agency pays an enhanced rate for covered
				pediatric care services and the administration of vaccines provided to clients
				age 20 and younger.
(2) For the
				purposes of this section, pediatric care services are defined as covered
				evaluation and management services.
(3) The agency uses the resource-based
				relative value scale (RBRVS) payment methodology described in WAC 182-531-1850
				to calculate the enhanced rate.
(4)
				If the enhanced rate is less than the agency's published fee schedule rate, the
				agency pays the published rate.
(5)
				This enhanced rate applies only to pediatric care services and administration
				of vaccines for clients age 20 and younger that are not already paid at an
				enhanced rate.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-2040 - Enhanced reimbursement-Medication assisted treatment for opioid use disorder

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency pays an enhanced reimbursement using the medicare rate when medication
				assisted treatment (MAT) is part of the visit for selected evaluation and
				management (E/M) codes and the provider meets the criteria in this
				section.
(2) The purpose of this
				enhanced reimbursement is to increase client access to evidence-based treatment
				using medications for opioid use disorder.
(3) To receive the enhanced reimbursement for
				MAT, a provider must:
(a) Bill using the
				agency's expedited prior authorization process;
(b) Bill for treating a client with a
				qualifying diagnosis for opioid use disorder; and
(c) Provide opioid-related counseling during
				the visit.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531A - Applied behavior analysis › Section 182-531A-0100 - Applied behavior analysis (ABA)-Purpose

Current through Register Vol. 24-14, July 15, 2024
Applied behavior analysis (ABA) assists clients and their
				  families to improve the core symptoms associated with autism spectrum disorders
				  and intellectual or developmental disabilities for which there is evidence ABA
				  is effective, per WAC
				  182-501-0165.
				  ABA services support learning, skill development, and assistance in any of the
				  following areas or domains: Social, behavior, adaptive, motor, vocational, or
				  cognitive.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531A - Applied behavior analysis › Section 182-531A-0300 - Applied behavior analysis (ABA)-Threshold requirements

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency pays for ABA services when the services
				  are:
(1) Covered;
(2) Medically necessary;
(3) Within the scope of the eligible client's
				medical care program;
(4) Provided
				to clients who meet the criteria in WAC
				182-531A-0400;
(5) Within currently accepted standards of
				evidence-based clinical practice;
(6) Not duplicative of ABA services paid for
				by other state agencies using medicaid funds;
(7) Completed in the stages described in this
				chapter;
(8) Provided by qualified
				health care professionals, as described in this chapter;
(9) Authorized, as required within this
				chapter, chapters 182-501 and 182-502 WAC, and the agency's
Applied
				Behavior Analysis Provider Guide
; and
(10) Billed according to this chapter,
				chapters 182-501 and 182-502 WAC, and the agency's
Applied Behavior
				Analysis Provider Guide
.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531A - Applied behavior analysis › Section 182-531A-0400 - Applied behavior analysis (ABA)-Client eligibility

Current through Register Vol. 24-14, July 15, 2024
To be eligible for applied behavior analysis (ABA) services,
				  a client must:
(1) Be covered under
				Washington apple health (WAH);
(2)
				Provide documentation created by a COE provider that:
(a) Establishes the presence of functional
				impairment; delay in communication, behavior, or social interaction; or
				repetitive or stereotyped behavior;
(b) Establishes that the client's impairment,
				delay, or behaviors adversely affect development or communication, or both,
				such that:
(i) The client cannot adequately
				participate in home, school, or community activities because the behavior or
				skill deficit interferes with these activities; or
(ii) The client's behavior endangers the
				client or another person, or impedes access to home and community activities;
				and
(c) An
				agency-recognized center of excellence (COE) provider has confirmed that:
(i) The client meets all requirements in (a)
				and (b) of this subsection;
(ii)
				The client has a qualifying diagnosis;
(A)
				Autism spectrum disorder; or
(B)
				Developmental/intellectual disability;
(iii) There is a reasonable expectation the
				requested services will result in measurable improvement in either the client's
				behavior, skills, or both; and
(iv)
				Either:
(A) Less intrusive or less intensive
				behavioral interventions have been tried and have not been successful;
				or
(B) No equally effective and
				substantially less costly alternative is available for reducing interfering
				behaviors, increasing pro-social skills and behaviors, or maintaining desired
				behaviors.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531A - Applied behavior analysis › Section 182-531A-0500 - Applied behavior analysis (ABA)-Stage one: COE evaluation and prescription

Current through Register Vol. 24-14, July 15, 2024
(1) Any
				person may refer a client suspected of meeting the criteria in WAC
				182-531A-0400 to a center of
				excellence (COE) provider for an evaluation.
(2) The individual COE provider must complete
				a comprehensive diagnostic evaluation and provide:
(a) Documentation showing how the autism
				spectrum disorder or other intellectual/developmental disability (for which
				there is evidence ABA is effective) diagnosis was made or confirmed by an
				approved individual COE provider that includes:
(i) Results of formal diagnostic procedures
				performed by a provider, including name of measure, dates, and results, as
				available; or
(ii) Clinical
				findings and observations used to confirm the diagnosis;
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531A - Applied behavior analysis › Section 182-531A-0600 - Applied behavior analysis (ABA)-Stage two: Functional assessment and treatment plan development

Current through Register Vol. 24-14, July 15, 2024
(1) If the
				center of excellence (COE) provider has prescribed applied behavior analysis
				(ABA) services, the client may begin stage two - ABA assessment, functional
				analysis, and ABA therapy treatment plan development.
(2) Prior authorization must be obtained from
				the agency prior to implementing the ABA therapy treatment plan. The prior
				authorization request must be received no more than 60 days from the date of
				the assessment and ABA therapy treatment plan. See WAC
				182-501-0165 for agency
				authorization requirements.
(3) The
				client or the client's legal guardian selects the ABA provider and the setting
				in which services will be rendered. ABA services may be rendered in one of the
				following settings:
(a) Day services program,
				which mean an agency-approved, outpatient facility or clinic-based program
				that:
(i) Employs or contracts with a lead
				behavior analysis therapist (LBAT), therapy assistant, speech therapist, and if
				clinically indicated, an occupational therapist, physical therapist,
				psychologist, medical provider, and dietitian;
(ii) Provides multidisciplinary services in a
				short-term day treatment program setting;
(iii) Delivers comprehensive intensive
				services;
(iv) Embeds early,
				intensive behavioral interventions in a developmentally appropriate
				context;
(v) Provides an
				individualized developmentally appropriate ABA therapy treatment plan for each
				client; and
(vi) Includes family
				support and training.