reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535A - Orthodontic services › Section 182-535A-0050 - Orthodontic treatment and orthodontic-related services-Authorization and prior authorization

Current through Register Vol. 24-14, July 15, 2024
When the medicaid agency authorizes a limited orthodontic
				  treatment, full orthodontic treatment, or orthodontic-related services for a
				  client, including a client eligible for services under the EPSDT program, that
				  authorization indicates only that the specific service is medically necessary;
				  authorization is not a guarantee of payment. The client must be eligible for
				  the covered service at the time the service is provided.
11-14-075, recodified as §
											182-535A-0050, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.04.050,
					 74.08.090. 08-17-009, §
					 388-535A-0050, filed 8/7/08, effective 9/7/08. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.520 and
					 74.09.035,
					 74.09.500. 05-01-064, §
					 388-535A-0050, filed 12/8/04, effective 1/8/05. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.035,
					 74.09.520,
					 74.09.500,
					 42 U.S.C.
					 1396 d(a), C.F.R. 440.100 and 225. 02-01-050,
					 § 388-535A-0050, filed 12/11/01, effective
					 1/11/02.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-535A - Orthodontic services › Section 182-535A-0060 - Orthodontic treatment and orthodontic-related services-Payment

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency pays providers for furnishing covered orthodontic treatment and
				orthodontic-related services described in WAC
				182-535A-0040
				according to this section and other applicable WAC.
(2) A provider who furnishes covered
				orthodontic treatment and orthodontic-related services to an eligible client
				accepts the agency's fees as published in the agency's fee schedules according
				to WAC
				182-502-0010.
(3) Providers must deliver services and
				procedures that are of acceptable quality to the agency.
(4) The agency may recoup payment, not
				limited to services:
(a) Determined to be
				below the standard of care; or
(b)
				Of an unacceptable product quality; or
(c) That are not rendered; or
(d) That do not address medical issue(s) as
				listed in the prior authorization request.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-537 - School-based health care services › Section 182-537-0100 - Purpose

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency pays contracted school districts,
				  educational service districts, charter schools, and tribal schools for
				  school-based health care services provided to medicaid-eligible children who
				  require early intervention or special education and related services consistent
				  with Sections 1903(c) and 1905(a) of the Social Security Act. The agency pays
				  school districts through fee-for-service. Covered services must:
(1) Identify, treat, and manage the
				disabilities of a child who requires early intervention or special education
				and related services;
(2) Be
				prescribed or recommended by licensed physicians or other licensed health care
				providers within their scope of practice under state law;
(3) Be medically necessary;
(4) Be included in the child's current
				individualized education program (IEP) or individualized family service plan
				(IFSP); and
(5) Be provided in a
				school setting, the natural environment, an alternate placement in accordance
				with the Individuals with Disabilities Education Act (IDEA), or by
				telemedicine.
Statutory Authority:
					 RCW
					 41.05.021. 13-05-017, §
											182-537-0100, filed 2/7/13,
					 effective 3/10/13. 11-14-075, recodified as §
											182-537-0100, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500, and
					 42 C.F.R.
					 440.110. 09-07-004, § 388-537-0100,
					 filed 3/4/09, effective 4/4/09. Statutory Authority:
					 RCW
					 74.08.090. 01-02-076, § 388-537-0100,
					 filed 12/29/00, effective 1/29/01. Statutory Authority:
					 RCW
					 74.04.050 and
					 74.08.090. 00-01-088, §
					 388-537-0100, filed 12/14/99, effective
					 1/14/00.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-537 - School-based health care services › Section 182-537-0300 - Student eligibility

Current through Register Vol. 24-14, July 15, 2024
(1) Contracted
				school districts may receive medicaid payment for students ages birth through
				twenty who:
(a) Have an active individualized
				family service plan (IFSP) or individualized education program (IEP);
				and
(b) Who are receiving Title XIX
				medicaid under a Washington apple health categorically needy program (CNP) or
				medically needy program (MNP).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-537 - School-based health care services › Section 182-537-0350 - Provider qualifications

Current through Register Vol. 24-14, July 15, 2024
(1)
				School-based health care services (SBHS) must be delivered by or under the
				supervision of health care providers who are enrolled with the medicaid agency
				and who meet state licensure requirements, including active, unrestricted
				department of health (DOH) licensure. The following people may provide SBHS:
(a) Licensed audiologists;
(b) Licensed social workers;
(c) Licensed mental health counselors (LMHC);
(d) Licensed mental health
				counselor associates (LMHCA) practicing under the supervision of a licensed
				mental health provider;
(e)
				Advanced registered nurse practitioners (ARNP);
(f) Registered nurses (RN);
(g) Licensed practical nurses (LPN)
				practicing under the supervision of an ARNP or licensed RN;
(h) Licensed occupational therapists (OT);
(i) Licensed occupational
				therapist assistants (OTA) practicing under the supervision of a licensed
				OT;
(j) Licensed physical
				therapists (PT);
(k) Licensed
				physical therapist assistants (PTA) practicing under the supervision of a
				licensed PT;
(l) Licensed
				psychologists;
(m) Licensed
				speech-language pathologists (SLP);
(n) Speech-language pathology assistants
				(SLPA) practicing under the supervision of a licensed SLP;
(o) Audiologist and speech language
				pathologist interim permit holders practicing under the supervision of a
				licensed audiologist or SLP; and
(p) Nonlicensed people providing services
				under the supervision of a licensed provider.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-537 - School-based health care services › Section 182-537-0400 - Covered services

Current through Register Vol. 24-14, July 15, 2024
Covered school-based health care (SBHS) services
				  include:
(1) Evaluations when the
				child is determined to have a disability, and is in need of early intervention
				services or special education and health care-related services that result in
				an individualized education program (IEP) or individualized family service plan
				(IFSP);
(2) Health care-related
				services authorized in an IEP or IFSP limited to:
(a) Audiology;
(b) School health services and school nursing
				services;
(c) Occupational
				therapy;
(d) Physical
				therapy;
(e) Mental health
				services; and
(f) Speech-language
				therapy.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-537 - School-based health care services › Section 182-537-0500 - Noncovered services

Current through Register Vol. 24-14, July 15, 2024
Noncov-ered services include, but are not limited to the
				  following:
(1) Applied behavior
				analysis (ABA);
(2) Attending
				meetings;
(3) Charting;
(4) Instructional assistant contact;
(5) Observation not provided
				directly after service delivery;
(6) Parent consultation;
(7) Parent contact;
(8) Planning;
(9) Preparing and sending correspondence to
				parents or other professionals;
(10) Professional consultation;
(11) Report writing;
(12) Review of records;
(13) School district staff accompanying a
				child who requires special education services to and from school on the bus
				when direct services are not provided;
(14) Supervision;
(15) Teacher contact;
(16) Test interpretation; and
(17) Travel and transporting.
Statutory Authority:
					 RCW
					 41.05.021. 13-05-017, §
											182-537-0500, filed 2/7/13,
					 effective 3/10/13. 11-14-075, recodified as §
											182-537-0500, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500, and
					 42 C.F.R.
					 440.110. 09-07-004, § 388-537-0500,
					 filed 3/4/09, effective 4/4/09.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-537 - School-based health care services › Section 182-537-0600 - School district requirements for billing and payment

Current through Register Vol. 24-14, July 15, 2024
To receive payment from the medicaid agency for providing
				  school-based health care services (SBHS) to eligible children, a school
				  district must:
(1) Enroll as a billing
				provider in Provider One and have a current, signed core provider agreement
				(CPA) with the agency.
(2) Have a
				current, signed, and executed SBHS contract with the agency.
(3) Meet the applicable requirements in
				chapter 182-502 WAC.
(4) Comply
				with the applicable requirements in the agency's current, published Provider
				One billing and resource guide.
(5)
				Bill according to the agency's current SBHS billing guide and the SBHS fee
				schedule.
(6) Provide only early
				intervention or health care-related services identified through a current
				individualized education program (IEP) or individualized family service plan
				(IFSP).
(7) Use only licensed
				health care providers or nonlicensed people practicing under the supervision of
				a licensed provider under WAC
				182-537-0350.
(8) Enroll licensed health care providers as
				servicing providers under the school district's Provider One account, and
				ensure providers have their own national provider identifier (NPI)
				number.
(9) Meet documentation
				requirements described in WAC
				182-537-0700.
Statutory
				  Authority:
				  RCW
				  41.05.021,
				  34 C.F.R.
				  300.154(d), and chapter
				  182-502 WAC. WSR 13-21-079, §
										182-537-0600, filed 10/17/13,
				  effective 11/17/13. Statutory Authority:
				  RCW
				  41.05.021. WSR 13-05-017, §
										182-537-0600, filed 2/7/13,
				  effective 3/10/13. WSR 11-14-075, recodified as §
										182-537-0600, filed 6/30/11,
				  effective 7/1/11. Statutory Authority:
				  RCW
				  74.08.090,
				  74.09.500, and
				  42 C.F.R.
				  440.110. WSR 09-07-004, § 388-537-0600,
				  filed 3/4/09, effective 4/4/09. WSR 13-21-003, §
										182-537-0600, filed 10/3/2013,
				  effective 11/3/2013
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-537 - School-based health care services › Section 182-537-0700 - School district documentation requirements

Current through Register Vol. 24-14, July 15, 2024
(1) Providers must
				document all school-based health care services as required in this section and
				the medicaid agency's school-based health care services (SBHS) billing
				guide.
(2) Documentation to justify
				billed claims must be maintained for at least six years from the date of
				service.
(3) Records for each
				student must include, but are not limited to:
(a) A referral or prescription for services
				by a physician or other licensed health care provider within their scope of
				practice;
(b) Assessment
				reports;
(c) Evaluation and
				reevaluation reports;
(d)
				Individualized education program (IEP) or individualized family service plan
				(IFSP);
(e) Attendance records;
				and
(f) Treatment notes. Treatment
				notes must include the:
(i) Child's
				name;
(ii) Child's Provider One
				client ID;
(iii) Child's date of
				birth;
(iv) Date of service, and
				for each date of service:
(A)
				Time-in;
(B) Time-out;
(C) A procedure code for and description of
				each service provided;
(D) The
				child's progress related to each service;
(E) Whether the occupational therapy,
				speech-language therapy, physical therapy or counseling service described in
				the note was individual or group therapy;
(F) The licensed provider's printed name,
				handwritten or electronic signature, and title; and
(G) Assistants and nonlicensed people, as
				defined in WAC
				182-537-0350, who provide early
				intervention or health care-related services under supervision, must have a
				licensed provider review and cosign all treatment
				notes.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-537 - School-based health care services › Section 182-537-0800 - Program integrity

Current through Register Vol. 24-14, July 15, 2024
(1) To ensure
				compliance with program rules, the medicaid agency conducts program integrity
				activities under chapters 182-502 and 182-502A WAC.
(2) School districts must participate in all
				program integrity activities.
(3)
				School districts are responsible for the accuracy, compliance, and completeness
				of all claims submitted for medicaid payment.
(4) The agency conducts reviews and recovers
				overpayments if a school district does not comply with agency requirements
				according to agency rules.
Statutory Authority:
					 RCW
					 41.05.021. 13-05-017, §
											182-537-0800, filed 2/7/13,
					 effective 3/10/13. 11-14-075, recodified as §
											182-537-0800, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500, and
					 42 C.F.R.
					 440.110. 09-07-004, § 388-537-0800,
					 filed 3/4/09, effective 4/4/09.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-040 - Introduction

Current through Register Vol. 24-14, July 15, 2024
(1) This chapter
				governs services provided under the Washington apple health integrated managed
				care (IMC) contract.
(2) IMC
				provides physical and behavioral health services to medicaid beneficiaries
				through managed care.
(3) IMC
				includes enrollees receiving behavioral health services only (BHSO).
(4) IMC medicaid services are available only
				through a contracted managed care organization (MCO) and its provider network,
				except as identified in this chapter.
(5) For nonmedicaid funded behavioral health
				wraparound services, see chapter 182-538B WAC.
(6) For crisis and crisis related behavioral
				health services, see chapter 182-538C WAC.
(7) For behavioral health services, also see
				chapter 182-538D WAC.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-060 - Managed care choice and assignment

Current through Register Vol. 24-14, July 15, 2024
(1)
				The medicaid agency requires a client to enroll in integrated managed care
				(IMC) when that client:
(a) Is eligible for
				one of the Washington apple health programs for which enrollment is
				mandatory;
(b) Resides in an area
				where enrollment is mandatory; and
(c) Is not exempt from IMC enrollment and the
				agency has not ended the client's managed care enrollment, consistent with WAC
				182-538-130.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-061

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
					 RCW
					 41.05.021, 42 C.F.R. 438. 13-02-010, §
											182-538-061, filed 12/19/12,
					 effective 2/1/13. 11-14-075, recodified as §
											182-538-061, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.09.522. 08-15-110, §
					 388-538-061, filed 7/18/08, effective 8/18/08; 06-03-081, § 388-538-061,
					 filed 1/12/06, effective 2/12/06. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.522, 2003 E 1 c 25§
					 201(4), 2004 c 276 § 201(4),
					 42 U.S.C.
					 1396 N (section 1915(b) and (c) of the Social
					 Security Act of 1924). 05-01-066, § 388-538-061, filed 12/8/04, effective
					 1/8/05.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-063

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
					 RCW
					 41.05.021, 42 C.F.R. 438. 13-02-010, §
											182-538-063, filed 12/19/12,
					 effective 2/1/13. Statutory Authority:
					 RCW
					 41.05.021,
					 74.09.035, and
					 2011 1st sp.s. c
					 36 . 12-19-051, §
											182-538-063, filed 9/13/12,
					 effective 10/14/12. 11-14-075, recodified as §
											182-538-063, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and 2007 c 522 § 209(13)
					 -(14). 08-10-048, § 388-538-063, filed 5/1/08, effective 6/1/08. Statutory
					 Authority:
					 RCW
					 74.04.050,
					 74.08.090,
					 74.09.530, and
					 74.09.700. 06-24-036, §
					 388-538-063, filed 11/30/06, effective 1/1/07. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.09.522. 06-03-081, §
					 388-538-063, filed 1/12/06, effective 2/12/06. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.035,
					 74.09.522, and 2003 1st sp.s. c 25
					 § 209(15). 04-15-003, § 388-538-063, filed 7/7/04, effective
					 8/7/04.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-065

Current through Register Vol. 24-14, July 15, 2024
Statutory Authority:
					 RCW
					 41.05.021, 42 C.F.R. 438. 13-02-010, §
											182-538-065, filed 12/19/12,
					 effective 2/1/13. 11-14-075, recodified as §
											182-538-065, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.09.522. 06-03-081, §
					 388-538-065, filed 1/12/06, effective 2/12/06. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.522, 2003 E 1 c 25§
					 201(4), 2004 c 276 § 201(4),
					 42 U.S.C.
					 1396 N (section 1915(b) and (c) of the Social
					 Security Act of 1924). 05-01-066, § 388-538-065, filed 12/8/04, effective
					 1/8/05. Statutory Authority:
					 RCW
					 74.09.080, 74.08.510, [74.08.]522,74.09.450 ,
					 1115 Waiver, 42 U.S.C.
					 1396. 02-01-075, § 388-538-065, filed
					 12/14/01, effective 1/14/02. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.510 and [74.09.]522 and 1115
					 Federal Waiver, 42 U.S.C.
					 1396(a), (e), (p),
					 42 U.S.C.
					 1396r-6(b),
					 42 U.S.C.
					 1396u-2. 00-04-080, § 388-538-065, filed
					 2/1/00, effective 3/3/00.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-067 - Qualifications to become a managed care organization (MCO) in integrated managed care

Current through Register Vol. 24-14, July 15, 2024
(1) To provide
				physical or behavioral health services under the apple health IMC contract, a
				managed care organization (MCO) must:
(a)
				Contract with the agency; and
(b)
				Contract with an agency-contracted behavioral health administrative service
				organization (BH-ASO) that maintains an adequate provider network to deliver
				services to clients in IMC regional service areas.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-068 - Qualifications to become a primary care case management (PCCM) provider in integrated managed care regional service areas

Current through Register Vol. 24-14, July 15, 2024
A primary care case management (PCCM) provider or the
				  individual providers in a PCCM group or clinic must:
(1) Have a core provider agreement with the
				medicaid agency;
(2) Be a
				recognized urban Indian health center or tribal clinic;
(3) Accept the terms and conditions of the
				agency's PCCM contract;
(4) Be able
				to meet the quality standards established by the agency; and
(5) Accept the case management rate paid by
				the agency.
Statutory Authority:
					 RCW
					 41.05.021, 42 C.F.R. 438. 13-02-010, §
											182-538-068, filed 12/19/12,
					 effective 2/1/13. 11-14-075, recodified as §
											182-538-068, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.09.522. 08-15-110, §
					 388-538-068, filed 7/18/08, effective 8/18/08; 06-03-081, § 388-538-068,
					 filed 1/12/06, effective 2/12/06. Statutory Authority:
					 RCW
					 74.09.080, 74.08.510,[74.08.]522 , 74.09.450,
					 1115 Waiver, 42 U.S.C.
					 1396. 02-01-075, § 388-538-068, filed
					 12/14/01, effective 1/14/02.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-070 - Payments, corrective action, and sanctions for managed care organizations (MCOs)

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency pays apple health managed care organizations (MCOs) monthly capitated
				premiums that:
(a) Have been developed using
				generally accepted actuarial principles and practices;
(b) Are appropriate for the populations to be
				covered and the services to be furnished under the MCO contract;
(c) Have been certified by actuaries who meet
				the qualification standards established by the American Academy of Actuaries
				and follow the practice standards established by the Actuarial Standards
				Board;
(d) Are based on analysis of
				historical cost, rate information, or both; and
(e) Are paid based on legislative
				allocations.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-071 - Payments for primary care case management (PCCM) providers in the integrated managed care for regional service areas

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency pays PCCM providers a
				monthly case management fee according to contracted terms and
				conditions.
(2) The agency pays
				PCCM providers for health care services under the fee-for-service health care
				delivery system.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-095 - Scope of care for integrated managed care enrollees and managed care organization benefit administration requirements

Current through Register Vol. 24-14, July 15, 2024
Scope of Care.
(1)
				An enrollee in integrated managed care (IMC) is eligible only for the scope of
				services that are covered based on the apple health program (eligibility
				program) in which they are enrolled.
(a) See
				the chart in WAC
				182-501-0060
				for category of covered services that are covered based on enrollee's apple
				health eligibility program, and the program rules to determine which specific
				services are covered. See WAC
				182-501-0065
				for a description of the category of covered services.
(b) The apple health eligibility programs for
				IMC includes the alternative benefit plan (ABP), categorically needy (CN), and
				medically needy (MN) programs.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-096 - Scope of service for PCCM enrollees

Current through Register Vol. 24-14, July 15, 2024
(1) An enrollee is entitled to timely access
				to covered services that are medically necessary.
(2) A primary care case management (PCCM)
				enrollee is eligible for the scope of services that are covered based on the
				enrollee's apple health eligibility program. See WAC
				182-501-0060
				and
				182-501-0065
				for categories of services that are covered and program rules for specific
				services that are covered.
(3) The
				agency covers services through the fee-for-service system for enrollees with a
				primary care case management (PCCM) provider.
(a) The PCCM provider must either provide the
				covered services or refer the enrollee to other providers who are contracted
				with the agency for covered services, except for emergency services.
(b) The PCCM provider is responsible for
				explaining to the enrollee how to obtain the services for which the PCCM
				provider is referring the enrollee.
(c) Services that require PCCM provider
				referral are described in the PCCM contract.
(d) The agency sends each enrollee written
				information about covered services when the client enrolls in managed care and
				when there is a change in covered services. This information describes covered
				services, which services are covered by the agency, and how to access services
				through the PCCM provider.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-100 - Managed care emergency services

Current through Register Vol. 24-14, July 15, 2024
(1)
				A managed care enrollee may obtain emergency services for emergency medical
				conditions from any qualified medicaid provider.
(a) The managed care organization (MCO)
				covers emergency services for MCO enrollees.
(b) The agency covers emergency services for
				primary care case management (PCCM) enrollees.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-110 - The grievance and appeal system and agency administrative hearing for managed care organization (MCO) enrollees

Current through Register Vol. 24-14, July 15, 2024
(1)
Introduction.
This section
				contains information about the grievance and appeal system and the right to an
				agency administrative hearing for MCO enrollees. See WAC
				182-538-111
				for information about PCCM enrollees.
(2)
Statutory basis and
				framework.
(a) Each MCO must have a
				grievance and appeal system in place for enrollees.
(b) Once an MCO enrollee has completed the
				MCO appeals process, the MCO enrollee has the option of requesting an agency
				administrative hearing regarding any adverse benefit determination upheld by
				the MCO. See chapter 182-526 WAC.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-111 - The administrative hearing process for primary care case management (PCCM)

Current through Register Vol. 24-14, July 15, 2024
PCCM enrollees follow the same administrative hearing rules
				  and processes as fee-for-service clients under chapter 182-526
				  WAC.
Statutory Authority:
					 RCW
					 41.05.021, 42 C.F.R. 438. 13-02-010, §
											182-538-111, filed 12/19/12,
					 effective 2/1/13. 11-14-075, recodified as §
											182-538-111, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.09.522. 08-15-110, §
					 388-538-111, filed 7/18/08, effective 8/18/08; 06-03-081, § 388-538-111,
					 filed 1/12/06, effective 2/12/06; 03-18-110, § 388-538-111, filed 9/2/03,
					 effective 10/3/03.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-120 - Enrollee request for a second medical opinion

Current through Register Vol. 24-14, July 15, 2024
(1) A managed care enrollee has the right to
				a timely referral for a second opinion upon request when:
(a) The enrollee needs more information about
				treatment recommended by the provider or managed care organization (MCO);
				or
(b) The enrollee believes the
				MCO is not authorizing medically necessary care.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-130 - Exemptions and ending enrollment in managed care

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency enrolls clients into integrated managed
				  care (IMC) based on the rules in WAC
				  182-538-060.
				  IMC is mandatory in all regional service areas.
(1)
Authority to request.
The
				following people may request that the agency approve an exemption or end
				enrollment in managed care:
(a) A client or
				enrollee;
(b) A client or
				enrollee's authorized representative under WAC
				182-503-0130;
				or
(c) A client or enrollee's
				representative as defined in
				RCW
				7.70.065.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-140 - Quality of care

Current through Register Vol. 24-14, July 15, 2024
To assure that managed care enrollees receive quality health
				  care services, the agency requires managed care organizations (MCOs) to comply
				  with quality improvement standards detailed in the agency's managed care
				  contract. MCOs must:
(1) Have a
				clearly defined quality organizational structure and operation, including a
				fully operational quality assessment, measurement, and improvement
				program;
(2) Have effective means
				to detect overutilization and underutilization of services;
(3) Maintain a system for provider and
				practitioner credentialing and recredentialing;
(4) Ensure that MCO subcontracts and the
				delegation of MCO responsibilities align with agency standards;
(5) Ensure MCO oversight of delegated
				entities responsible for any delegated activity to include:
(a) A delegation agreement with each entity
				describing the responsibilities of the MCO and the entity;
(b) Evaluation of the entity before
				delegation;
(c) An annual
				evaluation of the entity; and
(d)
				Evaluation or regular reports and follow-up on issues that are not compliant
				with the delegation agreement or the agency's managed care contract
				specifications;
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-150 - Apple health foster care program

Current through Register Vol. 24-14, July 15, 2024
(1)
				Unless otherwise stated in this section, all of the provisions of chapter
				182-538 WAC apply to apple health foster care (AHFC).
(2) The following sections of chapter 182-538
				WAC do not apply to AHFC:
(a) WAC
				182-538-068;
(b) WAC
				182-538-071;
(c) WAC
				182-538-096;
				and
(d) WAC
				182-538-111.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-190 - Behavioral health services only (BHSO)

Current through Register Vol. 24-14, July 15, 2024
This section applies to enrollees receiving behavioral health
				  services only (BHSO) under the integrated managed care (IMC) medicaid
				  contract.
(1) IMC is mandatory for
				clients in eligible programs, but the agency may end enrollment or exempt
				clients from IMC based on WAC
				182-538-130.
(2) If the agency ends enrollment or exempts
				a client from IMC, the client is required to enroll in behavioral health
				services only (BHSO). An exception to this requirement exists for American
				Indian and Alaskan native (AI/AN) clients. IMC including BHSO is optional for
				AI/AN clients.
(3) For BHSO
				enrollees, the MCO covers the behavioral health benefits included in the IMC
				medicaid contract, and the agency covers physical health services on a
				fee-for-service basis.
(4) The
				agency assigns the BHSO enrollee to an MCO available in the area where the
				client resides.
(5) A BHSO enrollee
				may change MCOs at any time for any reason with the change becoming effective
				the earliest possible date given the requirements of the agency's enrollment
				system.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538 - Managed care › Section 182-538-195 - Telemedicine and store and forward technology

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency's rules related to the authorized use of
				  telemedicine and store and forward technology are found in WAC
				  182-501-0300 and are applicable
				  to the benefits (including behavioral health services) administered by
				  agency-contracted managed care entities (managed care organizations and
				  behavioral health administrative service organizations) and fee-for-service
				  programs.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538B - Behavioral health wraparound services › Section 182-538B-040 - Behavioral health wraparound services

Current through Register Vol. 24-14, July 15, 2024
(1) This chapter governs nonmedicaid funded
				behavioral health services provided under the medicaid agency's behavioral
				health services wraparound contract. See also chapter 182-538D WAC for rules
				applicable to nonmedicaid behavioral health services.
(2) Washington apple health integrated
				managed care (IMC) behavioral health wraparound services are available only
				through a managed care organization (MCO) contracted to provide IMC
				services.
(3) The MCO provides
				contracted nonmedicaid funded behavioral health wraparound services to medicaid
				enrollees in an IMC regional service area:
(a) Within available resources;
(b) Based on medical necessity; and
(c) In order of priority to populations as
				identified by state and federal authorities.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538B - Behavioral health wraparound services › Section 182-538B-050 - Definitions

Current through Register Vol. 24-14, July 15, 2024
The following definitions and those found in chapters 182-500
				  and 182-538 WAC apply to this chapter, unless otherwise stated.
"Action"
means the denial or limited
				  authorization of a service covered under the behavioral health services
				  wraparound contract based on medical necessity.
"Available resources"
means funds appropriated
				  for the purpose of providing behavioral health wraparound services.
(a) This includes:
(i) Federal funds, except those provided according to Title
				  XIX of the Social Security Act; and
(ii) State funds appropriated by the legislature for the
				  purpose of providing services under the behavioral health administrative
				  services organization contract.
(b) This does not include funds appropriated for the purpose
				  of operating and administering the state psychiatric hospitals.
"Integrated managed care (IMC)"
See WAC
				  182-538-050.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538B - Behavioral health wraparound services › Section 182-538B-110 - Grievance and appeal system and agency administrative hearing

Current through Register Vol. 24-14, July 15, 2024
(1)
Introduction.
This section contains information about the managed
				care organization (MCO) grievance and appeal system and the agency's
				administrative hearing process for enrollees under the behavioral health
				services wraparound contract in integrated managed care (IMC) regional service
				areas.
(a) The MCO must have a grievance and
				appeal system and access to an agency administrative hearing to allow enrollees
				to file grievances and seek review of an MCO action as defined in this
				chapter.
(b) The agency's
				administrative hearing rules in chapter 182-526 WAC apply to agency
				administrative hearings requested by an enrollee to review the resolution of an
				enrollee's appeal of an MCO action.
(c) If a conflict exists between the
				requirements of this chapter and other rules, the requirements of this chapter
				take precedence.
(d) The MCO's
				policies and procedures regarding the grievance system must be approved by the
				agency.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538C - Crisis and noncrisis behavioral health services › Section 182-538C-040 - Behavioral health services

Current through Register Vol. 24-14, July 15, 2024
(1) This
				chapter governs crisis-related and other behavioral health services provided
				under the medicaid agency's behavioral health administrative services
				organization (BH-ASO) contract. See also chapter 182-538D WAC for rules
				applicable to nonmedicaid behavioral health services.
(2) The BH-ASO contracts with the agency to
				provide behavioral health services within an integrated managed care (IMC)
				regional service area.
(a) The BH-ASO
				provides the following services to all people, regardless of insurance status,
				income level, ability to pay, and county of residence:
(i) Mental health crisis services;
(ii) Operation of a behavioral health ombuds
				(ombudsman); and
(iii)
				Implementation of the Involuntary Treatment Act for both mental health and
				substance use disorders.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538C - Crisis and noncrisis behavioral health services › Section 182-538C-050 - Definitions

Current through Register Vol. 24-14, July 15, 2024
The definitions in this section and those found in chapters
				  182-500 and 182-538 WAC apply to this chapter.
"Action"
means the denial or limited
				  authorization of a service covered under the behavioral health administrative
				  services organization (BH-ASO) contract based on medical necessity.
"Available resources"
means funds appropriated
				  for the purpose of providing community behavioral health programs.
(a) This includes:
(i) Federal funds, except those provided according to Title
				  XIX of the Social Security Act; and
(ii) State funds appropriated by the legislature for the
				  purpose of providing services under the BH-ASO contract.
(b) This does not include funds appropriated for the purpose
				  of operating and administering the state psychiatric hospitals.
"Behavioral health"
- See WAC
				  182-538-050.
"Behavioral health administrative services organization
				  (BH-ASO)"
- See WAC
				  182-538-050.
"Complaint"
- See "grievance."
"Crisis"
- See WAC 182-538D-0200.
"Grievance"
- See WAC
				  182-538-050.
"Integrated managed care (IMC)"
- See WAC
				  182-538-050.
"Less restrictive alternative (LRA)"
means
				  court-ordered outpatient treatment in a setting less restrictive than total
				  confinement.
"Noncrisis services"
means services funded by
				  non-medicaid funding sources that are provided to people who are not enrolled
				  in Washington apple health or otherwise eligible for medicaid. These services
				  may be provided at the discretion of the behavioral health administrative
				  services organization (BH-ASO) within available resources, such as:
(a) Crisis stabilization;
(b) Outpatient mental health or substance use disorder
				  services; and
(c) Withdrawal management.
"Patient days of care"
- See WAC
				  182-538-050.
"Regional service area"
- See WAC
				  182-538-050.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538C - Crisis and noncrisis behavioral health services › Section 182-538C-070 - Payment

Current through Register Vol. 24-14, July 15, 2024
(1) For crisis
				services, the behavioral health administrative services organization (BH-ASO)
				must determine whether the person receiving the services is eligible for
				Washington apple health or if the person has any other form of insurance
				coverage.
(2) For people receiving
				crisis services who do not have other insurance coverage, the BH-ASO is
				responsible for the cost of those services.
(3) The BH-ASO administers and pays for the
				evaluation of involuntary detention or involuntary treatment under chapters
				71.05, 71.24, and 71.34 RCW.
(4)
				The BH-ASO pays a reimbursement for each state hospital patient day of care
				that exceeds the BH-ASO daily allocation of state hospital beds based on a
				quarterly calculation of the bed usage by the BH-ASO.
(a) The medicaid agency bills the BH-ASO
				quarterly for state hospital patient days of care exceeding the BH-ASO daily
				allocation of state hospital beds and the established rate of
				reimbursement.
(b) The BH-ASO using
				fewer patient days of care than its quarterly allocation of state hospital beds
				will receive a portion of the reimbursement collected proportional to its share
				of the total number of patient days of care that were not used at the
				appropriate state hospital.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538C - Crisis and noncrisis behavioral health services › Section 182-538C-110 - Grievance and appeal system and agency administrative hearing for behavioral health administrative services organizations (BH-ASOs)

Current through Register Vol. 24-14, July 15, 2024
(1)
General.
This section applies to the behavioral health
				administrative service organization (BH-ASO) grievance system for people within
				integrated managed care (IMC) regional service areas.
(a) The BH-ASO must have a grievance and
				appeal system to allow a person to file a grievance and request a review of a
				BH-ASO action as defined in this chapter.
(b) The agency's administrative hearing rules
				in chapter 182-526 WAC apply to agency administrative hearings requested by a
				person to review the resolution of an appeal of a BH-ASO action.
(c) If a conflict exists between the
				requirements of this chapter and other rules, the requirements of this chapter
				take precedence.
(d) The BH-ASO
				must maintain records of grievances and appeals.
(e) The BH-ASO is not obligated to continue
				services pending the results of an appeal or subsequent agency administrative
				hearing.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538C - Crisis and noncrisis behavioral health services › Section 182-538C-220 - Covered crisis mental health services

Current through Register Vol. 24-14, July 15, 2024
(1) Crisis mental health services are
				intended to stabilize a person in crisis to:
(a) Prevent further deterioration;
(b) Provide immediate treatment and
				intervention in a location best suited to meet the needs of the person;
				and
(c) Provide treatment services
				in the least restrictive environment available.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538C - Crisis and noncrisis behavioral health services › Section 182-538C-230 - Covered substance use disorder detoxification services

Current through Register Vol. 24-14, July 15, 2024
(1) Chemical
				dependency detoxification services are provided to a person to assist in the
				process of withdrawal from psychoactive substances in a safe and effective
				manner.
(2) A facility providing
				detoxification services to a person must:
(a)
				Be a facility licensed by the department of health under one of the following:
(i) Chapter 246-320 WAC;
(ii) Chapter 246-322 WAC;
(iii) Chapter 246-324 WAC; or
(iv) Chapter 246-337 WAC.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538C - Crisis and noncrisis behavioral health services › Section 182-538C-252 - Behavioral health administrative services organizations-Advisory board membership

Current through Register Vol. 24-14, July 15, 2024
(1) A behavioral
				health administrative services organization (BH-ASO) must appoint advisory
				board members and maintain an advisory board in order to:
(a) Promote active engagement with people
				with behavioral health disorders, their families, and behavioral health
				agencies; and
(b) Solicit and use
				the advisory board members input to improve service delivery and
				outcome.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538D - Behavioral health services › Section 182-538D-0234 - Behavioral health administrative service organizations-When the medicaid agency administers regional behavioral health services

Current through Register Vol. 24-14, July 15, 2024
(1) If a currently
				operating behavioral health administrative service organization (BH-ASO)
				chooses to stop functioning as a BH-ASO, fails to perform contract requirements
				and fails to correct the issue to the medicaid agency's satisfaction when
				corrective action is issued, or does not meet the requirements under
				RCW
				71.24.045, the following is implemented:
(a) Under
				RCW
				71.24.035(16), the director
				of the medicaid agency:
(i) Is designated as
				the BH-ASO until a new BH-ASO is designated; and
(ii) Assumes the duties assigned to the
				region without a participating BH-ASO.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538D - Behavioral health services › Section 182-538D-0246 - Behavioral health administrative service organizations and managed care organizations-Public awareness of behavioral health services

Current through Register Vol. 24-14, July 15, 2024
A behavioral health administrative service organization
				  (BH-ASO), or a managed care organization (MCO), or a BH-ASO's or MCO's designee
				  must provide public information on the availability of mental health and
				  substance use disorder services. The BH-ASO or MCO must:
(1) Maintain information on available
				services, including crisis services and the recovery help line in telephone
				directories, public web sites, and other public places in easily accessible
				formats; and
(2) Publish and
				disseminate brochures and other materials or methods for describing services
				and hours of operation that are appropriate for all people, including those who
				may be visually impaired, limited-English proficient, or unable to
				read.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-538D - Behavioral health services › Section 182-538D-0254 - Behavioral health administrative service organizations and managed care organizations-Voluntary and involuntary inpatient evaluation and treatment services

Current through Register Vol. 24-14, July 15, 2024
(1) A behavioral
				health administrative service organization (BH-ASO) and managed care
				organization (MCO) must develop and implement age and culturally competent
				behavioral health services that are consistent with chapters 71.24, 71.05, and
				71.34 RCW.
(2) For involuntary
				evaluation and treatment services, the BH-ASO or MCO:
(a) Must ensure that people in their regional
				service area have access to involuntary inpatient care; and
(b) Is responsible for coordinating discharge
				planning with the treating inpatient facility.