reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2565 - The long-term acute care (LTAC) program-General

Current through Register Vol. 24-14, July 15, 2024
The long-term acute care (LTAC) program is a
				  twenty-four-hour inpatient comprehensive program of integrated medical and
				  rehabilitative services provided in a medicaid agency-approved LTAC hospital
				  during the acute phase of a client's care. The agency requires prior
				  authorization for LTAC stays. See WAC
				  182-550-2590 for prior
				  authorization requirements.
(1) A
				facility's multidisciplinary team coordinates individualized LTAC services at
				an agency-approved LTAC hospital.
(2) The agency determines the authorized
				length of stay for LTAC services based on the client's need as documented in
				the client's medical records and the criteria described in WAC
				182-550-2590.
(3) When the agency-authorized length of stay
				ends, the provider transfers the client to a more appropriate level of care or,
				if appropriate, discharges the client to the client's residence.
11-14-075, recodified as §
											182-550-2565, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-11-129, §
					 388-550-2565, filed 5/22/07, effective 8/1/07. Statutory Authority:
					 RCW
					 74.08.090. 02-14-162, § 388-550-2565,
					 filed 7/3/02, effective 8/3/02.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2570

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-2570, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.09.500. 08-21-039, §
					 388-550-2570, filed 10/8/08, effective 11/8/08; 07-11-129, § 388-550-2570,
					 filed 5/22/07, effective 8/1/07. Statutory Authority:
					 RCW
					 74.08.090. 02-14-162, § 388-550-2570,
					 filed 7/3/02, effective 8/3/02.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2575 - Client eligibility requirements for LTAC services

Current through Register Vol. 24-14, July 15, 2024
Only a client who is eligible for one of the following
				  programs may receive LTAC services, subject to the restrictions and limitations
				  in WAC 182-550-1050,
				  182-550-2565,
				  182-550-2580,
				  182-550-2585,
				  182-550-2590,
				  182-550-2595,
				  182-550-2596, and other
				  rules:
(1) Categorically needy program
				(CNP);
(2) State children's health
				insurance program (SCHIP);
(3)
				Limited casualty program - Medically needy program (LCP-MNP);
(4) Alien emergency medical (AEM)(CNP);
				or
(5) Alien emergency medical
				(AEM)(LCP-MNP).
11-14-075, recodified as §
											182-550-2575, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-11-129, §
					 388-550-2575, filed 5/22/07, effective 8/1/07. Statutory Authority:
					 RCW
					 74.08.090. 02-14-162, § 388-550-2575,
					 filed 7/3/02, effective 8/3/02.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2580 - Requirements for becoming an LTAC hospital

Current through Register Vol. 24-14, July 15, 2024
(1) To apply to become a medicaid
				agency-approved long-term acute care (LTAC) hospital, the agency requires a
				hospital to:
(a) Submit a letter of request
				to:
LTAC Program Manager
Division of Health Care Services
Health and Recovery Services Administration
P.O. Box 45506
Olympia WA 98504-5506; and
(b) Include in the letter required under (a)
				of this subsection, documentation that confirms the hospital is:
(i) Medicare-certified for LTAC;
(ii) Accredited by the joint commission on
				accreditation of health care organizations (JCAHO);
(iii) Licensed as an acute care hospital by
				the department of health (DOH) under chapter 246-320 WAC (if an in-state
				hospital), or by the state in which the hospital is located (if an out-of-state
				hospital); and
(iv) Enrolled with
				the agency as a medic-aid participating provider.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2585 - LTAC hospitals-Quality of care

Current through Register Vol. 24-14, July 15, 2024
(1) To ensure quality of care, the medic-aid
				agency may conduct post-pay or on-site reviews of any agency-approved LTAC
				hospital. See chapter 182-502A WAC for additional information on audits
				conducted by agency staff.
(2) A
				provider of LTAC services must act on any reports of substandard care or
				violations of the hospital's medical staff bylaws. The provider must have and
				follow written procedures that provide a resolution to either a complaint or
				grievance or both.
(3) A complaint
				or grievance regarding substandard conditions or care may be investigated by
				any one or more of the following:
(a) The
				department of health (DOH);
(b) The
				joint commission on accreditation of health care organizations
				(JCAHO);
(c) The agency;
				or
(d) Other agencies with review
				authority for the agency's programs.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2590 - Agency prior authorization requirements for Level 1 and Level 2 LTAC services

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency requires prior authorization for Level 1 and Level 2 long term acute
				care (LTAC) inpatient stays. The prior authorization process includes all the
				following:
(a) For an initial 30-day stay:
(i) The client must:
(A) Be eligible under one of the programs
				listed in WAC
				182-550-2575; and
(B) Require Level 1 or Level 2 LTAC services
				as defined in WAC
				182-550-1050.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2595 - Identification of and payment methodology for services and equipment included in the LTAC fixed per diem rate

Current through Register Vol. 24-14, July 15, 2024
(1)
				In addition to room and board, the LTAC fixed per diem rate includes, but is
				not limited to, the following (see the medicaid agency's LTAC billing
				instructions for applicable revenue codes):
(a) Room and board -
				Rehabilitation;
(b) Room and board
				- Intensive care;
(c) Pharmacy - Up
				to and including two hundred dollars per day in total allowed covered charges
				for any combination of pharmacy services that includes prescription drugs,
				total parenteral nutrition (TPN) therapy, IV infusion therapy, and epogen or
				neupogen therapy;
(d)
				Medical/surgical supplies and devices;
(e) Laboratory - General;
(f) Laboratory - Chemistry;
(g) Laboratory - Immunology;
(h) Laboratory - Hematology;
(i) Laboratory - Bacteriology and
				microbiology;
(j) Laboratory -
				Urology;
(k) Laboratory - Other
				laboratory services;
(l)
				Respiratory services;
(m) Physical
				therapy;
(n) Occupational therapy;
				and
(o)  Speech-language
				therapy.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2596 - Services and equipment covered by the agency but not included in the LTAC fixed per diem rate

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency uses the ratio of costs-to-charges (RCC) payment method to pay an LTAC
				hospital for the following that are not included in the LTAC fixed per diem
				rate:
(a) Pharmacy - After the first two
				hundred dollars per day in total allowed covered charges for any combination of
				pharmacy services that includes prescription drugs, total par-enteral nutrition
				(TPN) therapy, IV infusion therapy, and epogen or neupogen therapy;
(b) Radiology services;
(c) Nuclear medicine services;
(d) Computerized tomographic (CT)
				scan;
(e) Operating room
				services;
(f) Anesthesia
				services;
(g) Blood storage and
				processing;
(h) Blood
				administration;
(i) Other imaging
				services - Ultrasound;
(j)
				Pulmonary function services;
(k) 
				Cardiology services;
(l) Recovery
				room services;
(m) EKG/ECG
				services;
(n) Gastro-intestinal
				services;
(o) Inpatient
				hemodialysis; and
(p) Peripheral
				vascular laboratory services.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2598 - Critical access hospitals (CAHs)

Current through Register Vol. 24-14, July 15, 2024
(1)
				The following definitions and abbreviations and those found in chapter 182-500
				WAC and WAC 182-182-1050 apply to this section:
(a) "CAH" see "critical access
				hospital."
(b) "Cost settlement"
				means a reconciliation of the fee-for-service interim CAH payments with a CAH's
				actual costs determined in conjunction with the use of the CAH's final settled
				medicare cost report (Form 2552-96) after the end of the CAH's HFY.
(c) "Critical access hospital (CAH)" means a
				hospital that is approved by the department of health (DOH) for inclusion in
				DOH's critical access hospital program.
(d) "HFY" see "Hospital fiscal
				year."
(e) "Hospital fiscal year"
				means each individual hospital's medicare cost report fiscal year.
(f) "Interim CAH payment" means the actual
				payment the medicaid agency makes for claims submitted by a CAH for service
				provided during its current HFY, using the appropriate weighted
				costs-to-charges (WCC) rate, as determined by the agency.
(g) "Revenue codes and procedure codes to
				cost centers crosswalk" means a document that indicates the revenue codes and
				procedure codes that are assigned by each hospital to a specific cost center in
				each hospital's medicare cost report.
(h) "Weighted costs-to-charges (WCC) rate"
				means a rate the agency uses to determine a CAH payment. See subsection (5) of
				this section for how the agency calculates a WCC rate.
(i) "WCC rate" see "weighted costs-to-charges
				rate."
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2600 - Inpatient psychiatric services

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency or the agency's designee pays for covered inpatient psychiatric services
				for eligible Washington apple health clients.
(2) The definitions found in chapter 182-500
				WAC and WAC
				182-550-1050 apply to this
				section.
(3) To be paid for an
				inpatient psychiatric admission, the hospital provider or hospital unit
				provider must meet the requirements for payment including the applicable
				general conditions of payment criteria in WAC
				182-502-0100.
(4) When billing the agency directly for
				Washington apple health clients not enrolled in an agency-contracted managed
				care organization(MCO) plan, hospitals may use the expedited prior
				authorization (EPA) process for inpatient psychiatric services that require
				authorization when the EPA criteria is met.
(a) To meet the EPA criteria, the inpatient
				admission must:
(i) Be medically
				necessary;
(ii) Have psychiatric
				needs as the focus of treatment and not have an acute medical
				condition;
(iii) Not have a
				less-restrictive placement available; and
(iv) Be approved or ordered by the
				professional in charge of the facility.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2650 - Base community psychiatric hospitalization payment method for medicaid and CHIP clients and nonmedicaid and non-CHIP clients

Current through Register Vol. 24-14, July 15, 2024
(1) Effective for dates of admission from
				July 1, 2005, through June 30, 2007, and in accordance with legislative
				directive, the agency implemented two separate base community psychiatric
				hospitalization payment rates, one for medicaid and children's health insurance
				program (CHIP) clients and one for nonmedicaid and non-CHIP clients. Effective
				for dates of admission on and after July 1, 2007, the base community
				psychiatric hospitalization payment method for medicaid and CHIP clients and
				nonmedicaid and non-CHIP clients is no longer used. (For the purpose of this
				section, a "nonmedicaid or non-CHIP client" is defined as a client eligible
				under the medical care services (MCS) program, as determined by the agency.)
(a) The medicaid base community psychiatric
				hospital payment rate is a minimum per diem for claims for psychiatric services
				provided to medicaid and CHIP covered patients, paid to hospitals that accept
				commitments under the Involuntary Treatment Act (ITA).
(b) The nonmedicaid base community
				psychiatric hospital payment rate is a minimum allowable per diem for claims
				for psychiatric services provided to indigent patients paid to hospitals that
				accept commitments under the ITA.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2750 - Hospital discharge planning services

Current through Register Vol. 24-14, July 15, 2024
For discharge planning service requirements, see chapter
				  246-320 WAC.
11-14-075, recodified as §
											182-550-2750, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,[74.09.]530
					 and 43.20B.020. 98-01-124, § 388-550-2750, filed 12/18/97, effective
					 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2800

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-2800, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.04.050,
					 74.04.057,
					 74.08.090,
					 74.09.500, and 2009-11 Omnibus
					 Operating Budget (ESHB 1244). 09-12-063, § 388-550-2800, filed 5/28/09,
					 effective 7/1/09. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-14-018, §
					 388-550-2800, filed 6/22/07, effective 8/1/07. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500, and 2005 c 518, §
					 204, Part II. 07-06-043, § 388-550-2800, filed 3/1/07, effective 4/1/07.
					 Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.520. 05-12-022, §
					 388-550-2800, filed 5/20/05, effective 6/20/05. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.09.500. 04-19-113, §
					 388-550-2800, filed 9/21/04, effective 10/22/04. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500,
					 74.09.035(1), and
					 43.88.290. 02-21-019, §
					 388-550-2800, filed 10/8/02, effective 11/8/02. Statutory Authority:
					 RCW
					 74.08.090 and
					 42 U.S.C.
					 1395 x(v),
					 42 C.F.R.
					 447.271, .11303, and .2652. 01-16-142, §
					 388-550-2800, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW
					 74.09.090, 42 U.S.C.
					 1395 x(v) and 1396r-4,
					 42 C.F.R.
					 447.271, 11303 and 2652. 99-14-027, §
					 388-550-2800, filed 6/28/99, effective 7/1/99. Statutory Authority:
					 RCW
					 74.08.090,
					 42 USC
					 1395 x(v),
					 42 C.F.R.
					 447.271, 447.11303, and 447.2652. 99-06-046,
					 § 388-550-2800, filed 2/26/99, effective 3/29/99. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200,[74.09.]500 ,
					 [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-2800, filed 12/18/97,
					 effective 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2900 - Payment limits-Inpatient hospital services

Current through Register Vol. 24-14, July 15, 2024
(1)
Eligibility for payment.
To
				be eligible for payment for covered inpatient hospital services, a hospital
				must:
(a) Have a core-provider agreement with
				the medicaid agency; and
(b) Be an
				in-state hospital, a bordering city hospital, a critical border hospital, or a
				distinct unit of that hospital, as defined in WAC
				182-550-1050; or
(c) Be an out-of-state hospital that meets
				the conditions in WAC
				182-550-6700.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2950 - Payment limits-Provider preventable fourteen-day readmissions

Current through Register Vol. 24-14, July 15, 2024
(1)
Introduction.
The rules in this section establish the medicaid
				agency's payment policy for inpatient claims for provider preventable
				fourteen-day readmissions and do not apply to any other rules regarding payment
				for hospital admissions.
(2)
Applicability.
The rules in this section apply to inpatient
				hospital claims made for clients enrolled in the fee-for-service program and to
				clients enrolled in an agency-contracted managed care organization (MCO).
(a) The rules in this section do not apply
				to:
(i) Professional claims submitted for
				services rendered in the inpatient setting during a readmission; or
(ii) Claims submitted by critical access
				hospitals.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3000 - Payment method

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency uses the diagnosis-related group (DRG) payment method to pay for covered
				inpatient hospital services, except as specified in WAC
				182-550-4300 and
				182-550-4400.
(2) The agency assigns a DRG code to each
				claim for an inpatient hospital stay using 3MT software (AP-DRG or APR-DRG) or
				other software currently in use by the agency. That DRG code determines the
				method used to pay claims for prospective payment system (PPS) hospitals. For
				the purpose of this section, PPS hospitals include all in-state and border area
				hospitals, except both of the following:
(a)
				Critical access hospitals (CAH), which the agency pays per WAC
				182-550-2598; and
(b) Military hospitals, which the agency pays
				using the following payment methods depending on the revenue code billed by the
				hospital:
(i) Ratio of costs-to-charges (RCC);
				and
(ii) Military subsistence per
				diem.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3010

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-3010, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.04.050,
					 74.04.057,
					 74.08.090,
					 74.09.500, and 2009-11 Omnibus
					 Operating Budget (ESHB 1244). 09-12-063, § 388-550-3010, filed 5/28/09,
					 effective 7/1/09. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500 and 2005 c 518.
					 07-14-051, § 388-550-3010, filed 6/28/07, effective
					 8/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3020

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-3020, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.04.050,
					 74.04.057,
					 74.08.090,
					 74.09.500, and 2009-11 Omnibus
					 Operating Budget (ESHB 1244). 09-12-063, § 388-550-3020, filed 5/28/09,
					 effective 7/1/09. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500 and 2005 c 518.
					 07-14-051, § 388-550-3020, filed 6/28/07, effective
					 8/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3100

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-3100, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500 and 2005 c 518.
					 07-14-051, § 388-550-3100, filed 6/28/07, effective 8/1/07. Statutory
					 Authority:
					 RCW
					 74.08.090,
					 74.04.050. 04-13-048, §
					 388-550-3100, filed 6/10/04, effective 7/11/04. Statutory Authority:
					 RCW
					 74.08.090,
					 42 USC
					 1395 x(v),
					 42 C.F.R.
					 447.271, 447.11303, and 447.2652. 99-06-046,
					 § 388-550-3100, filed 2/26/99, effective 3/29/99. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,
					 [74.09.]530 and43.20B.020 . 98-01-124, § 388-550-3100, filed 12/18/97,
					 effective 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3150

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-3150, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500 and 2005 c 518.
					 07-14-051, § 388-550-3150, filed 6/28/07, effective 8/1/07. Statutory
					 Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200,[74.09.]500 ,
					 [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-3150, filed 12/18/97,
					 effective 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3200

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-3200, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.09.500. 07-14-055, §
					 388-550-3200, filed 6/28/07, effective 8/1/07. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,[74.09.]530
					 and 43.20B.020. 98-01-124, § 388-550-3200, filed 12/18/97, effective
					 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3250

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-3250, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500 and 2005 c 518.
					 07-14-051, § 388-550-3250, filed 6/28/07, effective 8/1/07. Statutory
					 Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200,[74.09.]500 ,
					 [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-3250, filed 12/18/97,
					 effective 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3300

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-3300, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.09.500. 07-14-055, §
					 388-550-3300, filed 6/28/07, effective 8/1/07; 06-08-046, § 388-550-3300,
					 filed 3/30/06, effective 4/30/06. Statutory Authority:
					 RCW
					 74.04.050,
					 74.08.090. 05-12-132, §
					 388-550-3300, filed 6/1/05, effective 7/1/05. Statutory Authority:
					 RCW
					 74.08.090 and
					 42 U.S.C.
					 1395 x(v),
					 42 C.F.R.
					 447.271, .11303, and .2652. 01-16-142, §
					 388-550-3300, filed 7/31/01, effective 8/31/01. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,
					 [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-3300, filed 12/18/97,
					 effective 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3350

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-3350, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.09.500. 07-14-055, §
					 388-550-3350, filed 6/28/07, effective 8/1/07. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,[74.09.]530
					 and 43.20B.020. 98-01-124, § 388-550-3350, filed 12/18/97, effective
					 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3381 - Payment method for acute PM&R services and administrative day services

Current through Register Vol. 24-14, July 15, 2024
This section describes the agency's payment method for acute
				  physical medicine and rehabilitation (PM&R) services provided by acute
				  PM&R hospitals.
(1) The agency
				pays an acute PM&R hospital for acute PM&R services based on a
				rehabilitation per diem rate. See chapter 182-550 WAC and WAC
				182-550-3000.
(2) Acute PM&R room and board includes,
				but is not limited to:
(a) Facility
				use;
(b) Social services (e.g.,
				discharge planning);
(c) Bed and
				standard room furnishings; and
(d)
				Dietary and nursing services.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3400 - Case-mix index

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency calculates the case-mix index (CMI) for each individual hospital to
				measure the relative cost for treating medicaid and CHIP cases in a given
				hospital. The CMI represents the relative acuity of the claims.
(2) Using medicaid and children's health
				insurance program (CHIP) admissions data from the individual hospital and the
				hospital's base period cost report, the agency calculates the CMI by:
(a) Multiplying the number of medicaid and
				CHIP admissions to the hospital for a specific diagnosis-related group (DRG)
				classification by the relative weight for that DRG classification. The agency
				repeats this process for each DRG billed by the hospital;
(b) Adding together the products in (a) of
				this subsection for all of the medicaid and CHIP admissions to the hospital in
				the base year; and
(c) Dividing the
				sum obtained in (b) of this subsection by the corresponding number of medicaid
				and CHIP hospital admissions.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3450

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-3450, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500 and 2005 c 518.
					 07-14-051, § 388-550-3450, filed 6/28/07, effective 8/1/07. Statutory
					 Authority: RCW 74.09.090, 42
					 U.S.C. 1395 x(v) and 1396r-4,
					 42 C.F.R.
					 447.271, 11303 and 2652. 99-14-027, §
					 388-550-3450, filed 6/28/99, effective 7/1/99. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,[74.09.]530
					 and 43.20B.020. 98-01-124, § 388-550-3450, filed 12/18/97, effective
					 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3460

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-3460, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.04.050,
					 74.04.057,
					 74.08.090,
					 74.09.500, and 2009-11 Omnibus
					 Operating Budget (ESHB 1244). 09-12-063, § 388-550-3460, filed 5/28/09,
					 effective 7/1/09. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500 and 2005 c 518.
					 07-14-051, § 388-550-3460, filed 6/28/07, effective
					 8/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3470 - Payment method-Bariatric surgery-Per case rate

Current through Register Vol. 24-14, July 15, 2024
(1) Effective through June 30, 2019, the
				medicaid agency:
(a) Pays for bariatric
				surgery provided in designated agency-approved hospitals when all criteria
				established in WAC
				182-550-2301
				are met;
(b) Requires qualification
				and prior authorization of the provider before bariatric surgery related
				services are provided (see WAC
				182-550-2301
				); and
(c) Uses a per case rate to
				pay for bariatric surgery.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3500

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-3500, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.09.500. 07-14-055, §
					 388-550-3500, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW
					 74.09.090, 42 U.S.C.
					 1395 x(v) and 1396r-4,
					 42 C.F.R.
					 447.271, 11303 and 2652. 99-14-027, §
					 388-550-3500, filed 6/28/99, effective 7/1/99. Statutory Authority:
					 RCW
					 74.08.090,
					 42 USC
					 1395 x(v),
					 42 C.F.R.
					 447.271, 447.11303, and 447.2652. 99-06-046,
					 § 388-550-3500, filed 2/26/99, effective 3/29/99. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,
					 [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-3500, filed 12/18/97,
					 effective 1/18/98.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3600 - Diagnosis-related group (DRG) payment-Hospital transfers

Current through Register Vol. 24-14, July 15, 2024
(1) The rules in this section apply when an
				eligible client transfers from an acute care hospital or distinct unit to any
				of the following:
(a) Another acute care
				hospital or distinct unit;
(b) A
				skilled nursing facility (SNF);
(c)
				An intermediate care facility (ICF);
(d) Home care under the medicaid agency's
				home health program;
(e) A
				long-term acute care facility (LTAC);
(f) Hospice (facility-based or in the
				client's home);
(g) A
				hospital-based, medicare-approved swing bed, or another distinct unit such as a
				rehabilitation or psychiatric unit (see WAC
				182-550-3000 );
				or
(h) A nursing facility certified
				under medicaid but not medicare.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3700 - DRG high outliers

Current through Register Vol. 24-14, July 15, 2024
(1) The med-icaid
				agency identifies a diagnosis-related group (DRG) high outlier claim based on
				the claim's estimated costs. The agency allows a high outlier payment for
				claims paid using the DRG payment method when high outlier criteria are met.
(a) To qualify as a DRG high outlier claim,
				the estimated costs for the claim must be greater than the outlier threshold
				effective for the date of admission. The outlier threshold amount is depicted
				in the following table:
Dates of Admission
Pediatric
Nonpediatric
February 1, 2011 - July 31, 2012
Base DRG * 1.50
Base DRG * 1.75
August 1, 2012 - June 30, 2013
Base DRG * 1.429
Base DRG * 1.667
July 1, 2013 - June 30, 2014
Base DRG * 1.563
Base DRG * 1.823
July 1, 2014, and after
Base DRG + $40,000
Base DRG + $40,000
(b)
				The agency calculates the estimated costs of the claim by multiplying the total
				submitted charges, minus the nonallowed charges on the claim, by the hospital's
				ratio of costs-to-charges (RCC).
(c) When a transferring hospital submits a
				transfer claim to the agency, the high outlier criteria used to determine
				whether the claim qualifies for high outlier payment is the prorated DRG amount
				for the claim before the transfer payment .
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3800 - Rebasing

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency redesigns (rebases) the medicaid
				  inpatient payment system as needed. The base inpatient conversion factor and
				  per diem rates are only updated during a detailed rebasing process, or as
				  directed by the state legislature. Inpatient payment system factors such as the
				  ratio of costs-to-charges (RCC), weighted costs-to-charges (WCC), and
				  administrative day rate are rebased on an annual basis. As part of the
				  rebasing, the agency does all of the following:
(1) Gathers data. The agency uses the
				following data resources considered to be the most complete and available at
				the time:
(a) One year of paid claim data from
				the agency's medicaid management information system (MMIS). The agency
				excludes:
(i) Claims related to state programs
				and paid at the Title XIX reduced rates from the claim data; and
(ii) Critical access hospital claims paid per
				WAC 182-550-2598; and
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3830 - Adjustments to inpatient rates

Current through Register Vol. 24-14, July 15, 2024
(1)
				The medic-aid agency updates all of the following components of a hospital's
				specific diagnosis-related group (DRG) factor and per diem rates at rebase:
(a) Wage index adjustment;
(b) Direct graduate medical education (DGME);
				and
(c) Indirect medical education
				(IME).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3850 - Budget neutrality adjustment and measurement

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency measures the effectiveness of budget neutral rebasing by applying a
				budget neutrality adjustment factor to the base payment rates for both
				inpatient and outpatient hospitals as needed to maintain aggregate payments
				under rebased payment systems.
(a) The agency
				performs budget-neutrality adjustments and measurement by prospectively
				adjusting conversion factors and rates to offset unintentional aggregate
				payment system decreases or increases. The agency publishes conversion factors
				and rates which reflect any required budget neutrality adjustment.
(b) The following rates and factors are not
				adjusted by the BNAF:
(i) Inpatient per
				diem;
(ii) Ratio of
				costs-to-charges (RCC);
(iii)
				Critical access hospital (CAH) weighted costs-to-charges (WCC);
(iv) Inpatient pain management and
				rehabilitation (PM&R);
(v)
				Per-case rates;
(vi) Administrative
				day rates;
(vii) Long-term acute
				care (LTAC);
(viii) Substance-using
				pregnant people (SUPP);
(ix)
				Outlier parameters;
(x) Outpatient
				services paid at the resource-based relative value scale (RBRVS) fee;
(xi) Outpatient corneal transplants;
				and
(xii) Diabetic
				education.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-3900 - Payment method - Bordering city hospitals and critical border hospitals

Current through Register Vol. 24-14, July 15, 2024
The agency uses the payment methods described in this
				  section to pay bordering city hospitals and critical border hospitals for
				  inpatient and outpatient claims. Bordering city hospitals and critical border
				  hospitals are defined in WAC
				  182-550-1050.
(1) For inpatient hospital claims from
				bordering city hospitals, the agency calculates the payment for allowed covered
				charges related to medically necessary services, by using the lowest of the
				in-state inpatient hospital rates for the:
(a) Diagnosis-related group (DRG) conversion
				factor;
(b) Per diem payment
				method;
(c) Per case payment
				method; and
(d) Ratio of
				costs-to-charges (RCC) payment method.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-4000 - Payment method-Out-of-state hospitals

Current through Register Vol. 24-14, July 15, 2024
This section describes the payment methods the agency uses to
				  pay hospitals located out-of-state for providing services to eligible
				  Washington apple health clients. This section does not apply to hospitals
				  located in any of the designated bordering cities listed in WAC
				  182-501-0175. Payment methods
				  that apply to bordering city hospitals, including critical border hospitals,
				  are described in WAC
				  182-550-3900. See also WAC
				  182-501-0180, health care
				  services provided outside the state of Washington - General provisions, and WAC
				  182-502-0120, payment for health
				  care services provided outside the state of Washington.
(1) Emergency hospital services.
(a) For inpatient hospital claims for
				emergency services provided in out-of-state hospitals, the agency:
(i) Pays using the same methods used to pay
				in-state hospitals as specified in this chapter; and
(ii) Calculates the payment using the lowest
				in-state inpatient hospital rate corresponding to the payment method.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-4100 - Payment method-New hospitals

Current through Register Vol. 24-14, July 15, 2024
(1)
				For rate-setting purposes, the agency considers as new:
(a) A hospital which began services after the
				most recent rebasing; or
(b) A
				hospital that has not been in operation for a complete fiscal year.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-4200 - Change in hospital ownership

Current through Register Vol. 24-14, July 15, 2024
(1)
				For purposes of this section, a change in hospital ownership may involve one or
				more, but is not limited to, the following events:
(a)A change in the composition of the
				partnership;
(b)A sale of an
				unincorporated sole proprietorship;
(c)The statutory merger or consolidation of
				two or more corporations;
(d)The
				leasing of all or part of a provider's facility if the leasing affects
				utilization, licensure, or certification of the provider entity;
(e)The transfer of a government-owned
				institution to a governmental entity or to a governmental
				corporation;
(f) Donation of all or
				part of a provider's facility to another entity if the donation affects
				licensure or certification of the provider entity;
(g) Disposition of all or some portion of a
				provider's facility or assets through sale, scrapping, involuntary conversion,
				demolition, or abandonment if the disposition affects licensure or
				certification of the provider entity; or
(h) A change in the provider's federal
				identification tax number.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-4300 - Hospitals and units exempt from the DRG payment method

Current through Register Vol. 24-14, July 15, 2024
(1) Except when
				otherwise specified, inpatient services provided by hospitals and units that
				are exempt from the diagnosis-related group (DRG) payment method are paid under
				the ratio of costs-to-charges (RCC) payment method described in WAC
				182-550-4500, the per diem
				payment method described in WAC
				182-550-3000, the per case rate
				payment method described in WAC
				182-550-3000, or other payment
				methods identified in this chapter (e.g., long term acute care (LTAC),
				certified public expenditure (CPE), critical access hospital (CAH), etc.).
				Inpatient services provided by hospitals and units are exempt from the DRG
				payment method only if they qualify for payment methods specifically mentioned
				in other sections of this chapter or in this section.
(2) The agency exempts the following
				hospitals, units, and services from the DRG payment method for inpatient
				services provided to clients eligible for Washington apple health:
(a) Hospitals participating in the agency's
				certified public expenditure (CPE) payment program (see WAC
				182-550-4650) ;
(b) Hospitals participating in the agency's
				critical access hospital program (see WAC
				182-550-2598) ;
(c) Rehabilitation services. All
				rehabilitation services are paid through the per diem payment method except as
				indicated in (a), (b), and (d) of this subsection (see WAC
				182-550-3000) ;
(d) Military hospitals when no other specific
				arrangements have been made with the agency. The agency, or the military
				hospital, may elect or arrange for one of the following payment methods in lieu
				of the RCC payment method:
(i) Per diem
				payment method; or
(ii) DRG payment
				method; and
(e)
				Psychiatric services. All psychiatric services are paid through the per diem
				payment method except as indicated in (a), (b), and (d) of this subsection (see
				WAC 182-550-3000). An agency designee
				that arranges to directly pay a hospital and/or a designated distinct
				psychiatric unit of a hospital may use the agency's payment methods or contract
				with the hospital to pay using different methods.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-4400 - Services-Exempt from DRG payment

Current through Register Vol. 24-14, July 15, 2024
(1) Inpatient
				services are exempt from the diagnosis-related group (DRG) payment method only
				if they qualify for payment methods specifically mentioned in other sections of
				this chapter or in this section.
(2) Subject to the restrictions and
				limitations in this section, the agency exempts the following services for
				medicaid and CHIP clients from the DRG payment method. This policy also applies
				to covered services paid through medical care services (MCS) and any other
				state-administered program, except when otherwise indicated in this section.
				The exempt services are:
(a) Withdrawal
				management services when provided in a hospital having a withdrawal management
				provider agreement with the agency to perform these services.
(b) Hospital-based intensive inpatient
				withdrawal management, medical stabilization, and drug treatment services
				provided to substance-using pregnant people (SUPP) clients by an
				agency-approved hospital. These are medicaid program services and are not
				covered or funded by the agency through MCS or any other state-administered
				program.
(c) Acute physical
				medicine and rehabilitation (acute PM&R) services.
(d) Psychiatric services. An agency designee
				that arranges to pay a hospital directly for psychiatric services may use the
				agency's payment methods or contract with the hospital to pay using different
				methods.
(e) Chronic pain
				management treatment provided in a hospital approved by the agency to provide
				that service.
(f) Administrative
				day services. The agency pays administrative days for one or more days of a
				hospital stay in which an acute inpatient or observation level of care is not
				medically necessary, and a lower level of care is appropriate. The
				administrative day rate is based on the statewide average daily medicaid
				nursing facility rate, which is adjusted annually. The agency may designate
				part of a client's stay to be paid an administrative day rate upon review of
				the claim or the client's medical record, or both.
(g) Inpatient services recorded on a claim
				grouped by the agency to a DRG for which the agency has not published an
				all-patient DRG (AP-DRG) or all-patient refined DRG (APR-DRG) relative weight.
				The agency will deny payment for claims grouped to APR DRG 955 or APR DRG
				956.
(h) Organ transplants that
				involve heart, intestine, kidney, liver, lung, allogeneic bone marrow,
				autologous bone marrow, pancreas, or simultaneous kidney/pancreas. The agency
				pays hospitals for these organ transplants using the ratio of costs-to-charges
				(RCC) payment method. The agency maintains a list of DRGs which qualify as
				transplants on the agency's website.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-4500 - Payment method-Ratio of costs-to-charges (RCC)

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency pays hospitals using the ratio of costs-to-charges (RCC) payment method
				for services exempt from the following payment methods:
(a) Ambulatory payment classification
				(APC);
(b) Diagnosis-related group
				(DRG);
(c) Enhanced ambulatory
				patient group (EAPG);
(d) Per
				case;
(e) Per diem; and
(f) Maximum allowable fee schedule.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-4550 - Administrative day rate and swing bed day rate

Current through Register Vol. 24-14, July 15, 2024
(1)
Administrative day rate.
(a) The
				medicaid agency allows hospitals an administrative day rate for those days of
				hospital stay in which a client does not meet criteria for acute inpatient
				level of care, but is not discharged because:
(i) An appropriate placement outside the
				hospital is not available (no placement administrative day); or
(ii) The postpartum parent's newborn remains
				on an inpatient claim for monitoring post-in utero exposure to substances that
				may lead to physiologic dependence and continuous care by the postpartum parent
				is the appropriate first-line treatment (newborn administrative day).
				"Postpartum parent" means the client who delivered the baby(ies).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-4600

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-4600, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-12-040, §
					 388-550-4600, filed 5/30/07, effective 7/1/07; 06-08-046, § 388-550-4600,
					 filed 3/30/06, effective 4/30/06. Statutory Authority:
					 RCW
					 74.04.050,
					 74.08.090. 05-12-132, §
					 388-550-4600, filed 6/1/05, effective 7/1/05. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.730,
					 74.04.050,
					 70.01.010,
					 74.09.200, [74.09.]500,
					 [74.09.]530 and43.20B.020 . 98-01-124, § 388-550-4600, filed 12/18/97,
					 effective 1/18/98.