reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-500 - Medical definitions › Section 182-500-0095 - Medical assistance definitions-R

Current through Register Vol. 24-14, July 15, 2024
"Reasonably compatible"
means the amount of a
				  person's self-attested income or resources (as defined in WAC
				  182-500-0100) and the amount of a
				  person's income or resources verified via electronic data sources are either
				  both above or both below the applicable income or resources standard for
				  Washington apple health (WAH). When self-attested income or resources is less
				  than the standard for WAH, but income or resources from available data sources
				  is more than the WAH standard, or when the self-attested income or resources
				  cannot be verified via electronic data sources, the self-attested income or
				  resources are considered not reasonably compatible.
"Retroactive period"
means approval of medical
				  coverage for any or all of the retroactive period. A client may be eligible
				  only in the retroactive period or may have both current eligibility and a
				  separate retroactive period of eligibility approved.
11-14-075, recodified as §
											182-500-0095, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and 2011 1st sp.s. c 15. 11-14-053,
					 § 388-500-0095, filed 6/29/11, effective
					 7/30/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-500 - Medical definitions › Section 182-500-0100 - Medical assistance definitions-S

Current through Register Vol. 24-14, July 15, 2024
"Self-attestation"
means a person's written,
				  verbal, or electronic declaration of the person's income, resources, or
				  circumstances made under penalty of perjury, confirming a statement to be true.
				  (See also "attested income" or "attested resources.")
"Spenddown"
is a term used in the medically
				  needy (MN) program and means the process by which a person uses incurred
				  medical expenses to offset income and/or resources to meet the financial
				  standards established by the agency. See WAC
				  182-519-0110.
"Spouse"
means a person who is legally married
				  to another person. Washington state recognizes other states' determinations of
				  legal and common-law marriages between two persons.
(1)
"Community spouse"
means a
				person who:
(a) Does not reside in a medical
				institution; and
(b) Is legally
				married to a client who resides in a medical institution or receives services
				from a home and community-based waiver program. A person is considered married
				if not divorced, even when physically or legally separated from the person's
				spouse.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-500 - Medical definitions › Section 182-500-0105 - Medical assistance definitions-T

Current through Register Vol. 24-14, July 15, 2024
"Tax dependent"
means a person for whom a tax
				  filer claims an exemption on his or her federal income tax return. A tax
				  dependent may be either a qualifying child or a qualifying relative under 26
				  U.S.C. Sec. 152 for a taxable year.
"Tax filer"
means a person who expects to file a
				  federal income tax return.
"Third party"
means an entity other than the
				  medicaid agency or the agency's designee that may be liable to pay all or part
				  of the cost of health care for a Washington apple health (WAH) client.
"Third-party liability (TPL)"
means the legal
				  responsibility of an identified third party or parties to pay all or part of
				  the cost of health care for a WAH client. See client obligations in
				  establishing TPL under WAC
				  182-503-0540.
"Title XIX"
is the portion of the federal Social
				  Security Act, 1396 et seq., that authorizes funding to states for health care
				  programs. Title XIX is also called medicaid.
"Title XXI"
is the portion of the federal Social
				  Security Act, 42 U.S.C.
				  1397aa et seq., that authorizes funding to
				  states for the children's health insurance program (CHIP).
"Transfer of assets"
means changing ownership or
				  title of an asset such as income, real property, or personal property by one of
				  the following:
(a) An intentional act
				that changes ownership or title; or
(b) A failure to act that results in a change
				of ownership or title.
11-14-075, recodified as §
											182-500-0105, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and 2011 1st sp.s. c 15. 11-14-053,
					 § 388-500-0105, filed 6/29/11, effective
					 7/30/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-500 - Medical definitions › Section 182-500-0110 - Medical assistance definitions - U

Current through Register Vol. 24-14, July 15, 2024
"Urgent care"
means an unplanned appointment for
				  a covered medical service with verification from an attending physician or
				  facility that the client must be seen that day or the following day.
"Usual and customary charge"
means the amount a
				  provider typically charges to fifty percent or more of patients who are not
				  medical assistance clients.
11-14-075, recodified as §
											182-500-0110, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and 2011 1st sp.s. c 15. 11-14-053,
					 § 388-500-0110, filed 6/29/11, effective
					 7/30/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-500 - Medical definitions › Section 182-500-0120 - Medical assistance definitions - W

Current through Register Vol. 24-14, July 15, 2024
"Washington apple health"
means the public
				  health insurance programs for eligible Washington residents. Washington apple
				  health is the name used in Washington state for medicaid, the children's health
				  insurance program (CHIP), and state-only funded health care programs.
"Washington Healthplanfinder"
is a marketplace
				  for individuals, families, and small businesses in Washington state to compare
				  and enroll in health insurance coverage and gain access to premium tax credits,
				  reduced cost sharing, and public programs such as Washington apple health.
				  Washington Healthplanfinder is administered by the Washington health benefit
				  exchange.
Statutory Authority:
					 RCW
					 41.05.021, Patient Protection and Affordable
					 Care Act ( Public Law
					 111-148 ), 42 C.F.R. §§ 431, 435, and
					 457, and 45 C.F.R. § 155. WSR 13-14-019, §
											182-500-0120, filed 6/24/13,
					 effective 7/25/13.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0050 - Health care general coverage

Current through Register Vol. 24-14, July 15, 2024
WAC 388-501-0050 through 388-501-0065 describe the health
				  care services available to a client on a fee-for-service basis or to a client
				  enrolled in a managed care organization (MCO) (defined in WAC 388-538-050 ).
				  For the purposes of this section, health care services includes treatment,
				  equipment, related supplies, and drugs. WAC 388-501-0070 describes noncovered
				  services.
(1) Health care service
				categories listed in WAC 388-501-0060 do not represent a contract for health
				care services.
(2) For the provider
				to receive payment, the client must be eligible for the covered health care
				service on the date the health care service is performed or provided.
(3) Under the department's fee-for-service
				programs, providers must be enrolled with the department and meet the
				requirements of chapter 388-502 WAC to be paid for furnishing health care
				services to clients.
(4) The
				department pays only for the health care services that are:
(a) Within the scope of the client's medical
				program;
(b) Covered - See
				subsection (9) of this section;
(c)
				Ordered or prescribed by a health care provider who meets the requirements of
				chapter 388-502 WAC;
(d) Medically
				necessary as defined in WAC 388-500-0005;
(e) Submitted for authorization, when
				required, in accordance with WAC 388-501-0163;
(f) Approved, when required, in accordance
				with WAC 388-501-0165;
(g)
				Furnished by a provider according to chapter 388-502 WAC; and
(h) Billed in accordance with department
				program rules and the department's current published billing instructions and
				numbered memoranda.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0055 - Health care coverage - How the agency determines coverage of services for its health care programs using health technology assessments

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency uses health technology assessments to determine whether a new
				technology, new indication, or existing technology approved by the Food and
				Drug Administration (FDA) is a covered service under agency health care
				programs. The agency only uses health technology assessments when coverage is
				not mandated by federal or state law. A health technology assessment may be
				conducted by or on behalf of:
(a)The agency;
				or
(b)The health technology
				assessment clinical committee (HTACC) under
				RCW
				70.14.080 through
				70.14.140.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0060 - Health care coverage-Program benefit packages-Scope of service categories

Current through Register Vol. 24-14, July 15, 2024
(1) This rule
				provides a table that lists:
(a) The
				following Washington apple health programs:
(i) The alternative benefits plan (ABP)
				medicaid;
(ii) Categorically needy
				(CN) medicaid;
(iii) Medically
				needy (MN) medicaid; and
(iv)
				Medical care services (MCS) programs (includes incapacity-based and aged,
				blind, and disabled medical care services), as described in WAC
				182-508-0005;
				and
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0070 - Health care coverage-Noncovered services

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency or its designee does
				not pay for any health care service not listed or referred to as a covered
				health care service under the medical programs described in WAC
				182-501-0060,
				regardless of medical necessity. For the purposes of this section, health care
				services includes treatment, equipment, related supplies, and drugs.
				Circumstances in which clients are responsible for payment of health care
				services are described in WAC
				182-502-0160.
(2) This section does not apply to health
				care services provided as a result of the early and periodic screening,
				diagnosis, and treatment (EPSDT) program as described in chapter 182-534
				WAC.
(3) The agency or its designee
				does not pay for any ancillary health care service(s) provided in association
				with a noncovered health care service.
(4) The following list of noncovered health
				care services is not intended to be exhaustive. Noncovered health care services
				include, but are not limited to:
(a) Any
				health care service specifically excluded by federal or state law;
(b) Acupuncture, Christian Science practice,
				faith healing, herbal therapy, homeopathy, massage, massage therapy,
				naturopathy, and sanipractice;
(c)
				Chiropractic care for adults;
(d)
				Cosmetic, reconstructive, or plastic surgery, and any related health care
				services, not specifically allowed under WAC
				182-531-0100(4)
				or
				182-531-1675;
(e) Discography;
(f) Ear or other body piercing;
(g) Face lifts or other facial cosmetic
				enhancements;
(h) Fertility,
				infertility or sexual dysfunction testing, and related care, drugs, and/or
				treatment including but not limited to:
(i)
				Artificial insemination;
(ii) Donor
				ovum, donor sperm, or gestational carrier;
(iii) In vitro fertilization;
(iv) Penile implants;
(v) Reversal of sterilization; and
(vi) Sex therapy.
(i) Hair transplants;
(j) Epilation (hair removal) and electrolysis
				not specifically allowed under WAC
				182-531-1675;
(k) Marital counseling;
(l) Motion analysis, athletic training
				evaluation, work hardening condition, high altitude simulation test, and health
				and behavior assessment;
(m)
				Nonmedical equipment;
(n) Penile
				implants;
(o) Prosthetic testicles
				not specifically allowed under WAC
				182-531-1675;
(p) Psychiatric sleep therapy;
(q) Subcutaneous injection filling;
(r) Tattoo removal;
(s) Transport of Involuntary Treatment Act
				(ITA) clients to or from out-of-state treatment facilities, including those in
				bordering cities;
(t) Upright
				magnetic resonance imaging (MRI); and
(u) Vehicle purchase - New or used
				vehicle.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0100 - Subrogation

Current through Register Vol. 24-14, July 15, 2024
(1) For the purpose
				of this section, means:
(a)The tort-feasor,
				or insurer of the tort-feasor, or both; and
(b)Any person, entity or program that is or
				may be liable to provide coverage for the illness or injuries for which the
				medicaid agency is providing assistance or residential care.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0125 - Advance directives

Current through Register Vol. 24-14, July 15, 2024
In this section "advance directive" means a written
				  instruction, recognized under state law, relating to the provision of health
				  care when an individual is incapacitated.
(1) All agencies, health maintenance
				organizations (HMOs), and facilities including hospitals, critical access
				hospitals, skilled nursing and nursing facilities, and providers of in-home
				care services that serve medical assistance clients eighteen years of age or
				older must have written policies and procedures concerning advance
				directives.
(2) The agencies, HMOs,
				and facilities must give the following information to each adult client, in
				writing and orally, and in a language the client understands:
(a) A statement about the client's right to:
(i) Make decisions concerning the client's
				medical care;
(ii) Accept or refuse
				surgical or medical treatment;
(iii) Execute an advance directive;
(iv) Revoke an advance directive at any
				time;
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0135 - Patient review and coordination (PRC)

Current through Register Vol. 24-14, July 15, 2024
(1)
Patient review and coordination
				(PRC)
is a health and safety program that coordinates care and ensures
				clients enrolled in PRC use services appropriately and in accordance with
				agency rules and policies.
(a) PRC applies to
				medical assistance fee-for-service (FFS) clients and managed care organization
				(MCO) enrollees.
(b) PRC is
				authorized under federal medicaid law by
				42 U.S.C.
				1396n(a)(2) and
				42 C.F.R.
				431.54.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0160 - Exception to rule - Request for a noncovered health care service

Current through Register Vol. 24-14, July 15, 2024
A client or the client's provider may request that the
				  medicaid agency or its designee pay for a noncovered health care service. This
				  is called an exception to rule (ETR). The request for ETR must be made before
				  the service is rendered.
(1) The
				agency's medical director or designee evaluates and considers requests on a
				case-by-case basis. The agency's medical director has final authority to
				approve or deny a request for ETR.
(2) The agency or its designee cannot approve
				an ETR if the requested service is excluded under state statute.
(3) Any item or service for which an ETR is
				requested must :
(a) Fall within accepted
				standards and precepts of good medical practice;
(b) Represent cost-effective use of public
				funds; and
(c) Be submitted to the
				agency or its designee in writing within ninety days of the date of the written
				notification denying authorization for the noncovered service.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0163 - Health care coverage - Process for submitting a valid request for authorization

Current through Register Vol. 24-14, July 15, 2024
(1) The
				medicaid agency requires providers to obtain authorization for certain health
				care services under this section, chapters 182-501 and 182-502 WAC, other
				applicable agency rules, current published agency billing instructions, and
				numbered memoranda. For the purposes of this section, health care services
				include treatment, equipment, related supplies, and drugs.
(a)For health care services that require
				prior authorization (PA), a provider (as defined in WAC
				182-500-0085 ) must submit a
				written, electronic, or telephonic request to the agency. To be a valid request
				for PA, the provider must send the request and follow the agency's current
				published program billing instructions, numbered memoranda, and any additional
				requirements in Washington Administrative Code (WAC) and Revised Code of
				Washington (RCW).
(b)For expedited
				prior authorization (EPA), a provider must certify that the client's clinical
				condition meets the appropriate EPA criteria outlined in the agency's current
				published program billing instructions, numbered memoranda, and any additional
				requirements in WAC and RCW. The provider must use the agency-assigned EPA
				number when submitting a claim for payment to the agency.
(c)The agency requires PA for covered health
				care services when the applicable EPA criteria are not met.
(d)Upon request, a provider must send
				documentation to the agency showing how the client's condition meets the
				required criteria for PA or EPA.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0165 - Medical and dental coverage- Fee-for-service (FFS) prior authorization-Determination process for payment

Current through Register Vol. 24-14, July 15, 2024
(1)
				This section applies to fee-for-service (FFS) requests for medical or dental
				services and medical equipment that:
(a) Are
				identified as covered services or early and periodic screening, diagnosis, and
				treatment services; and
(b) Require
				prior authorization by the medicaid agency.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0169 - Health care coverage - Limitation extension

Current through Register Vol. 24-14, July 15, 2024
This section addresses requests for limitation extensions
				  regarding scope, amount, duration, and frequency of a covered health care
				  service. For the purposes of this section, health care services includes
				  treatment, equipment, related supplies, and drugs. The medicaid agency does not
				  authorize or pay for any covered health care services exceeding identified
				  limitations unless authorization is obtained before the client receives the
				  service.
(1)No limitation extension of
				covered health care services is authorized when prohibited by specific program
				rules.
(2)When a limitation
				extension is not prohibited by specific program rules, the client's provider
				may request a limitation extension.
(3) The agency evaluates requests for
				limitation extensions as follows:
(a)For a
				fee-for-service client, the process described in WAC
				182-501-0165.
(b) For a managed care enrollee, the client's
				managed care organization (MCO) evaluates requests for limitation extensions
				according to the MCO's prior authorization process.
(c) Both the agency and MCO consider the
				following in evaluating a request for a limitation extension:
(i) The level of improvement the client has
				shown to date related to the requested health care service and the reasonably
				calculated probability of continued improvement if the requested health care
				service is extended; and
(ii) The
				reasonably calculated probability the client's condition will worsen if the
				requested health care service is not extended.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0175 - Medical care provided in bordering cities

Current through Register Vol. 24-14, July 15, 2024
(1) An eligible Washington state resident may
				receive medical care in a recognized out-of-state bordering city on the same
				basis as in-state care.
(2) The
				only recognized bordering cities are:
(a)
				Coeur d'Alene, Moscow, Sandpoint, Priest River, and Lewiston, Idaho;
				and
(b) Portland, The Dalles,
				Hermiston, Hood River, Rainier, Milton-Freewater, and Astoria,
				Oregon.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0180 - Health care services provided outside the state of Washington-General provisions

Current through Register Vol. 24-14, July 15, 2024
WAC 182-501-0180 through
				  182-501-0184
				  describe the health care services available to a Washington apple health client
				  on a fee-for-service basis or to a client enrolled in a managed care
				  organization (MCO) (defined in WAC
				  182-538-050 ).
(1) Subject to the requirements, exceptions,
				and limitations in this section, WAC
				182-501-0182,
				and
				182-501-0184,
				the medicaid agency covers emergency and nonemergency out-of-state health care
				services provided to eligible Washington apple health recipients when the
				services are:
(a) Within the scope of the
				client's or enrollee's health care program as specified under chapter 182-501
				WAC or other program rules;
(b)
				Allowed to be provided outside the state of Washington by specific program WAC;
				and
(c) Medically necessary as
				defined in WAC
				182-500-0070.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0182 - Health care provided in another state or U.S. territory - Nonemergency

Current through Register Vol. 24-14, July 15, 2024
(1) This rule
				applies to nonemergency treatment situations occurring in another state or U.S.
				territory. Applicable situations include, but are not limited to:
(a)Health care services the medicaid agency
				has prior authorized for a client; and
(b)Health care services obtained by the
				client, independent of the agency, while traveling or visiting.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0184 - Health care services provided outside of the United States and U.S. territories or in a foreign country

Current through Register Vol. 24-14, July 15, 2024
For the purposes of this section, the term "health care
				  services" does not include the diagnosis and treatment for alcohol , substance
				  abuse, and mental health services.
(1)The provisions of WAC
				182-501-0182 apply to this
				section.
(2)The medicaid agency
				does not pay for health care services furnished in a foreign country, except
				for medical services furnished in the province of British Columbia, Canada,
				under this section. The agency pays for medical services furnished in British
				Columbia, Canada, to Washington apple health (WAH) clients only when those
				clients:
(a) Reside in Point Roberts,
				Washington;
(b) Reside in
				Washington communities along the border with British Columbia, Canada (see
				subsection (3) of this section for further clarification); or
(c)Are members of the Canadian First Nations
				who live in Washington state.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0200 - Third-party resources

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency requires a provider to seek timely reimbursement from a responsible
				third party when a client has available third-party resources, except as
				described under subsections (2) and (3) of this section. Responsible third
				parties include health insurers and other third parties legally liable for
				health care items and services received by clients.
(2) The agency pays for medical services and
				seeks reimbursement from a responsible third party when the claim is for
				preventive pediatric services as covered under the early and periodic
				screening, diagnosis and treatment (EPSDT) program.
(3) The agency pays for medical services and
				seeks reimbursement from any responsible third party when both of the following
				apply:
(a) The provider submits to the agency
				documentation of billing the third party and the provider has not received
				payment after 100 days from the date of services; and
(b) The claim is for a covered service
				provided to a client on whose behalf the office of support enforcement is
				enforcing a noncustodial parent to pay support. For the purpose of this
				section, "is enforcing" means the noncustodial parent either:
(i) Is not complying with an existing court
				order; or
(ii) Received payment
				directly from the third party and did not pay for the medical
				services.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0213 - Case management services

Current through Register Vol. 24-14, July 15, 2024
(1)
				The medicaid agency provides case management services to Washington apple
				health recipients:
(a)By contract with
				providers of case management services.
(b)Limited to target groups of clients as
				determined by the contract.
(c)Limited to services as determined by the
				contract.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0215 - Wraparound with intensive services (WISe)

Current through Register Vol. 24-14, July 15, 2024
(1) Wraparound with
				intensive services (WISe) is a service delivery model that provides
				comprehensive behavioral health covered services and support to:
(a) Clients age 20 or younger with complex
				behavioral health needs who are eligible for coverage under WAC
				182-505-0210; and
(b) Their families.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-501 - Administration of medical programs-General › Section 182-501-0300 - Telemedicine and store and forward technology

Current through Register Vol. 24-14, July 15, 2024
(1)
Purpose
				and scope.
(a) This section identifies
				the requirements and limitations for coverage, authorization, and payment of
				health care services provided through telemedicine or store and forward
				technologies as defined in subsection (2) of this section.
(b) This section applies to health care
				services, including behavioral health services, provided to clients enrolled
				in:
(i) An agency-contracted managed care
				organization (MCO) and fee-for-service programs; and
(ii) Other agency-contracted programs,
				including grant-funded health care services and health care services
				administered by behavioral health administrative services organizations
				(BH-ASOs).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › PROVIDER TYPES › Section 182-502-0002 - Eligible provider types

Current through Register Vol. 24-14, July 15, 2024
The following health care professionals, health care
					 entities, suppliers or contractors of service may request enrollment with the
					 Washington state health care authority (medicaid agency) to provide covered
					 health care services to eligible clients. For the purposes of this chapter,
					 health care services include treatment, equipment, related supplies, and
					 drugs.
(1) Professionals:
(a) Advanced registered nurse
				  practitioners;
(b) Advanced social
				  workers;
(c) Advanced social worker
				  associates;
(d)
				  Anesthesiologists;
(e) Applied
				  behavior analysis (ABA) professionals, as provided in WAC
				  182-531A-0800:
(i) Licensed behavior analyst;
(ii) Licensed assistant behavior analyst;
				  and
(iii) Certified behavior
				  technician;
(f)
				  Audiologists;
(g)
				  Chiropractors;
(h)
				  Dentists;
(i) Dental health aide
				  therapists, as provided in chapter 70.350 RCW;
(j) Dental hygienists;
(k) Denturists;
(l) Dietitians or nutritionists;
(m) Hearing aid fitters/dispensers;
(n) Home health aide credentialed with DOH as
				  nursing assistant certified or nursing assistant registered;
(o) Independent clinical social
				  workers;
(p) Independent clinical
				  social worker associates;
(q)
				  Licensed practical nurse;
(r)
				  Marriage and family therapists;
(s)
				  Mental health counselors;
(t)
				  Mental health counselor associates;
(u) Mental health care providers;
(v) Midwives;
(w) Naturopathic physicians;
(x) Nurse anesthetist;
(y) Ocularists;
(z) Occupational therapists;
(aa) Ophthalmologists;
(bb) Opticians;
(cc) Optometrists;
(dd) Orthodontists;
(ee) Orthotist;
(ff) Osteopathic physicians;
(gg) Osteopathic physician
				  assistants;
(hh) Peer
				  counselors;
(ii) Podiatric
				  physicians;
(jj)
				  Pharmacists;
(kk)
				  Physicians;
(ll) Physician
				  assistants;
(mm) Physical
				  therapists;
(nn)
				  Prosthetist;
(oo)
				  Psychiatrists;
(pp)
				  Psychologists;
(qq)
				  Radiologists;
(rr) Registered
				  nurse;
(ss) Registered nurse
				  delegators;
(tt) Registered nurse
				  first assistants;
(uu) Respiratory
				  therapists;
(vv) Speech/language
				  pathologists; and
(ww) Substance
				  use disorder professionals:
(i) Mental health
				  providers; and
(ii) Peer
				  counselors.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › PROVIDER TYPES › Section 182-502-0003 - Noneligible provider types

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency does not enroll licensed or unlicensed
					 health care practitioners not specifically listed in WAC
					 182-502-0002, including, but not
					 limited to:
(1)
				  Acupuncturists;
(2)
				  Sanipractors;
(3)
				  Homeopaths;
(4)
				  Herbalists;
(5) Massage
				  therapists;
(6) Christian science
				  practitioners, theological healers, and spiritual healers;
(7) Chemical dependency professional trainee
				  (CDPT); and
(8) Mental health
				  trainee (MHT).
11-14-075, recodified as §
												182-502-0003, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.08.090,
						74.09.080, and
						74.09.290. 11-11-017, §
						388-502-0003, 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 › ENROLLMENT › Section 182-502-0005 - Core provider agreement (CPA)

Current through Register Vol. 24-14, July 15, 2024
(1) The agency only
				  pays claims submitted for services provided by or on behalf of:
(a) A health care professional, health care
				  entity, supplier or contractor of service that has an approved core provider
				  agreement (CPA) with the agency;
(b) A servicing provider enrolled under an
				  approved CPA with the agency; or
(c) A provider who has an approved agreement
				  with the agency as a nonbilling provider in accordance with WAC
				  182-502-0006.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › ENROLLMENT › Section 182-502-0006 - Enrollment for nonbilling individual providers

Current through Register Vol. 24-14, July 15, 2024
(1) The agency pays for health care services,
				  drugs, supplies or equipment prescribed, ordered, or referred by a health care
				  professional only when the health care professional has one of the following
				  approved agreements with the agency and all other conditions of payment have
				  been met (see WAC
				  182-501-0050 ):
(a) Core provider agreement, in accordance
				  with WAC 182-502-0005; or
(b) Nonbilling provider agreement, in
				  accordance with subsection (4) of this section.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › ENROLLMENT › Section 182-502-0012 - When the medicaid agency does not enroll

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency does not enroll a
				  health care professional, health care entity, supplier, or contractor of
				  service for reasons which include, but are not limited to, the following:
(a) The agency determines that:
(i) There is a quality of care issue with
				  significant risk factors that may endanger client health, or safety, or both
				  (see WAC
				  182-502-0030(1)(a)
				  ); or
(ii) There are risk factors
				  that affect the credibility, honesty, or veracity of the health care
				  practitioner (see WAC
				  182-502-0030(1)(b)
				  ).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › ENROLLMENT › Section 182-502-0014 - Review and consideration of an applicant's history

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency may consider
				  enrolling a health care professional, health care entity, supplier or
				  contractor of service for reasons which include, but are not limited to, the
				  following:
(a) The agency determines that:
(i) There is not a quality of care issue with
				  significant risk factors that endanger client health or safety, or
				  both;
(ii) There are not risk
				  factors that affect the credibility, honesty, or veracity of the applicant;
				  and
(iii) The applicant is not
				  likely to repeat the violation that led to a restriction or sanction.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › PROVIDER REQUIREMENTS › Section 182-502-0017 - Employee education about false claims recovery

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency (agency) requires any
				  entity (including providers) that makes or receives medical assistance payments
				  from the agency or the agency desig-nee of at least $5,000,000 annually under
				  the state plan to meet the requirements of Section 1902 (a)(68) of the Social
				  Security Act in order to receive payments.
(2)
Entity policies and
				  procedures
. Entities must adopt and disseminate policies and procedures
				  for their employees, contractors, and agents regarding federal and state false
				  claims and whistleblower protection laws.
(a)
				  Written policies and procedures may be in paper or electronic form, but must be
				  readily available to all employees, contractors, and agents.
(b) If the entity has an employee handbook,
				  it must include a specific discussion of the laws described in written policies
				  regarding the rights of employees to be protected as whistleblowers, and a
				  specific discussion of the entity's policies and procedures for detecting and
				  preventing fraud, waste, and abuse.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › PROVIDER REQUIREMENTS › Section 182-502-0018 - Change of ownership

Current through Register Vol. 24-14, July 15, 2024
(1) A provider must
				  notify the medicaid agency in writing within seven calendar days of ownership
				  or control changes of any kind. An entity is considered to have an ownership or
				  control interest in another entity if it has direct or indirect ownership of
				  five percent or more, or is a managing employee (e.g., a general manager,
				  business manager, administrator, or director) who exercises operational or
				  managerial control over the entity or who directly or indirectly conducts
				  day-to-day operations of the entity. The agency determines whether a new core
				  provider agreement (CPA) must be completed for the new entity.
(2) When a provider obtains a new federal tax
				  identification (ID) following a change of ownership, the agency terminates the
				  provider's CPA as of the date of the change in federal tax ID. The provider may
				  reapply for a new CPA.
(3) All new
				  ownership enrollments are subject to the requirements in WAC
				  182-502-0010. In addition to
				  those requirements, the applicant must:
(a)
				  Complete a change of ownership form;
(b) Provide the agency with a copy of the
				  contract of sale identifying previous and current owners; and
(c) Provide the agency with a list of all
				  provider numbers affected by the change of ownership.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › PROVIDER REQUIREMENTS › Section 182-502-0020 - Health care record requirements

Current through Register Vol. 24-14, July 15, 2024
This section applies to providers, as defined under WAC
					 182-500-0085 and under WAC
					 182-538-050. Providers
					 must:
(1) Maintain documentation in
				  the client's medical or health care records to verify the level, type, and
				  extent of services provided to each client to fully justify the services and
				  billing, including, but not limited to:
(a)
				  Client's name and date of birth;
(b) Dates of services;
(c) Name and title of person performing the
				  service;
(d) Chief complaint or
				  reason for each visit;
(e)
				  Pertinent past and present medical history;
(f) Pertinent findings on examination at each
				  visit;
(g) Medication(s) or
				  treatment prescribed and/or administered;
(h) Name and title of individual prescribing
				  or administering medication(s);
(i)
				  Equipment and/or supplies prescribed or provided;
(j) Name and title of individual prescribing
				  or providing equipment and/or supplies;
(k) Detailed description of treatment
				  provided;
(l) Subjective and
				  objective findings;
(m) Clinical
				  assessment and diagnosis;
(n)
				  Recommendations for additional treatments, procedures, or
				  consultations;
(o) Radiographs (X
				  rays), diagnostic tests and results;
(p) Plan of treatment and/or care, and
				  outcome;
(q) Specific claims and
				  payments received for services;
(r)
				  Correspondence pertaining to client dismissal or termination of health care
				  practitioner/patient relationship;
(s) Advance directives, when required under
				  WAC 182-501-0125;
(t) Patient treatment agreements (examples:
				  Opioid agreement, medication and treatment compliance agreements);
				  and
(u) Informed consent
				  documentation.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › PROVIDER REQUIREMENTS › Section 182-502-0022 - Provider preventable conditions (PPCs)-Payment policy

Current through Register Vol. 24-14, July 15, 2024
(1) This section
				  establishes the agency's payment policy for services provided to medicaid
				  clients on a fee-for-service basis or to a client enrolled in a managed care
				  organization (defined in WAC
				  182-538-050) by health care
				  professionals and inpatient hospitals that result in provider preventable
				  conditions (PPCs).
(2) The rules in
				  this section apply to:
(a) All health care
				  professionals who bill the agency directly; and
(b) Inpatient hospitals.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › PROVIDER REQUIREMENTS › Section 182-502-0025 - Electronic health records (EHR) incentive program

Current through Register Vol. 24-14, July 15, 2024
The purpose of this section is to establish the medicaid
					 electronic health records (EHR) incentive program under the American Recovery
					 and Reinvestment Act of 2009 (ARRA). The medicaid EHR incentive program
					 promotes the adoption and meaningful use of certified EHR technology by
					 offering financial incentives to eligible professionals and hospitals. This
					 program is administered by the medicaid agency.
(1) The agency provides incentive payments to
				  eligible providers and hospitals that adopt and meaningfully use certified EHR
				  technology under 42 C.F.R. Parts 412, 413, 422, and any other federal
				  regulations that apply.
(2)
				  Providers and hospitals eligible to participate in EHR incentive program are
				  identified in 42 C.F.R. Part 495.304 and other applicable rules.
(3) As authorized by 42 C.F.R. Parts 412,
				  413, 422, chapters 43.20B and 74.09 RCW, and any other federal or state rules
				  that apply, the agency monitors and reviews all providers and hospitals
				  participating in the EHR incentive program. By the same authority, the agency
				  reviews all practices, documentation, and data related to EHR technology to
				  determine whether professionals and hospitals participating in the EHR
				  incentive program are eligible and complying with state and federal rules and
				  regulations.
(4) The agency may
				  determine that a participating professional or hospital has not met the
				  eligibility or performance requirements to receive an EHR incentive payment, or
				  should receive an incentive payment in an amount less than the amount
				  anticipated by the provider or hospital. Areas of possible dispute in the EHR
				  incentive program include, at a minimum, any of the following:
(a) Patient volume thresholds and
				  calculations, as outlined in 42 C.F.R. Parts 495.304 and 495.306.
(b) Eligibility criteria and payment
				  limitations, as outlined in 42 C.F.R. Parts 495.10, 495.304, 495.306, and
				  495.310.
(c) Attestations and
				  compliance demonstrations including, at a minimum:
(i) Attestations that certified EHR
				  technology has been adopted, implemented, or upgraded; and
(ii) Demonstrations of meaningful use, as
				  outlined in 42 C.F.R. Parts 495.6, 495.8, 495.306, 495.310, and in any future
				  published federal regulations and requirements, as applicable.
(d) The payment process and
				  incentive payment amounts, as outlined in 42 C.F.R. Parts 495.310, 495.312, and
				  495.314.
(e) Additional issues
				  regarding EHR incentive program eligibility, participation, documentation, and
				  compliance as outlined in 42 C.F.R. Parts 412, 413, 422 , and in any future
				  published federal regulations and requirements, as applicable.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › TERMINATION OF PROVIDER › Section 182-502-0030 - Termination of provider enrollment-For cause

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency may immediately terminate a provider's enrollment for any one or more of
				  the following reasons, each of which constitutes cause:
(a) Provider exhibits significant risk
				  factors that endanger client health or safety. These factors include, but are
				  not limited to:
(i) Moral turpitude;
(ii) Sexual misconduct according to chapter
				  246-16 WAC or in profession specific rules of the department of health
				  (DOH);
(iii) A statement of
				  allegations or statement of charges by DOH or equivalent from other state
				  licensing boards;
(iv) Restrictions
				  or limitations placed by any state licensing, credentialing, or certification
				  agency on the provider's current credentials or practice;
(v) Limitations, restrictions, or loss of
				  hospital privileges or participation in any health care plan or failure to
				  disclose the reasons to the agency;
(vi) Negligence, incompetence, inadequate or
				  inappropriate treatment, or lack of appropriate follow-up treatment;
(vii) Patient drug mismanagement, failure to
				  identify substance use disorder, or failure to refer the patient for substance
				  use disorder treatment once identified;
(viii) Use of health care providers or health
				  care staff who are unlicensed to practice or who provide health care services
				  that are outside their recognized scope of practice or the standard of practice
				  in the state of Washington;
(ix)
				  Failure of the health care provider to comply with the requirements of WAC
				  182-502-0016;
(x) Failure of the health care provider with
				  a substance use disorder(s) to furnish documentation or other assurances as
				  determined by the agency to adequately safeguard the health and safety of
				  Washington apple health clients that the provider:
(A) Is complying with all conditions,
				  limitations, or restrictions to the provider's practice both public and
				  private; and
(B) Is receiving
				  treatment adequate to ensure that the disorder will not affect the quality of
				  the provider's practice.
(xi) Infection control
				  deficiencies;
(xii) Failure to
				  maintain adequate professional malpractice coverage;
(xiii) Medical malpractice claims or
				  professional liability claims that constitute a pattern of questionable or
				  inadequate treatment, or contain any gross or flagrant incident of malpractice;
				  or
(xiv) Any other act that the
				  agency determines is contrary to the health and safety of its
				  clients.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-502 - Administration of medical programs-Providers › TERMINATION OF PROVIDER › Section 182-502-0040 - Termination of a provider agreement-For convenience

Current through Register Vol. 24-14, July 15, 2024
(1) Either the medicaid agency or the
				  provider may terminate the provider's participation with the agency for
				  convenience with thirty calendar days written notice served upon the other
				  party in a manner which provides proof of receipt or proof of valid attempt to
				  deliver.
(2) Terminations for
				  convenience are not eligible for the dispute resolution process described in
				  WAC
				  182-502-0050.
				  Terminations for convenience are eligible for reconsideration as described in
				  WAC
				  182-502-0012.
(3) If a provider is terminated for
				  convenience, the agency pays for authorized services provided up to the date of
				  termination only.
11-14-075, recodified as §
												182-502-0040, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.08.090,
						74.09.080, and
						74.09.290. 11-11-017, §
						388-502-0040, filed 5/9/11, effective
						6/9/11.