reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › AUTHORIZATION › Section 182-530-3100 - How the medicaid agency determines when a drug requires authorization

Current through Register Vol. 24-14, July 15, 2024
(1) The medic-aid
				  agency's pharmacists or medical consultants periodically evaluate covered
				  drugs, covered indications, or new dosages approved by the Food and Drug
				  Administration (FDA) to determine the drug authorization requirement.
(a) The clinical team evaluates and grades
				  available information for each drug or drug class based on quality evidence
				  contained in compendia of drug information and peer-reviewed medical
				  literature. The information evaluated includes, but is not limited to:
(i) Evidence for efficacy and
				  safety;
(ii) Cost comparisons of
				  drugs with similar existing drugs;
(iii) Potential for clinical
				  misuse;
(iv) Potential for client
				  misuse or abuse;
(v) Drugs with a
				  narrow therapeutic index;
(vi)
				  Other safety concerns; or
(vii)
				  Product cost and outcome data demonstrating the cost effectiveness of the drug,
				  device, or drug-related supply.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › AUTHORIZATION › Section 182-530-3200 - The medicaid agency's authorization process

Current through Register Vol. 24-14, July 15, 2024
(1) The agency may establish automated ways
				  for pharmacies to meet authorization requirements for specified drugs, devices,
				  and drug-related supplies, or circumstances as listed in WAC
				  182-530-3000 including, but not
				  limited to:
(a) Use of expedited
				  authorization codes as published in the agency's prescription drug program
				  billing instructions ;
(b) Use of
				  specified values in national council of prescription drug programs (NCPDP)
				  claim fields;
(c) Use of diagnosis
				  codes; and
(d) Evidence of previous
				  therapy within the agency's claim history.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › QUALITY OF CARE › Section 182-530-4000 - Drug use review (DUR) board

Current through Register Vol. 24-14, July 15, 2024
In accordance with
					 42 C.F.R.
					 456.716, the medicaid agency establishes a
					 drug use review (DUR) board.
(1) The
				  DUR board:
(a) Includes health professionals
				  who are actively practicing and licensed in the state of Washington and who
				  have recognized knowledge and expertise in one or more of the following:
(i) The clinically appropriate prescribing of
				  outpatient drugs;
(ii) The
				  clinically appropriate dispensing and monitoring of outpatient drugs;
(iii) Drug use review, evaluation, and
				  intervention; and
(iv) Medical
				  quality assurance.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › QUALITY OF CARE › Section 182-530-4050 - Drug use and claims review

Current through Register Vol. 24-14, July 15, 2024
(1) The
				  agency's drug use review (DUR) consists of:
(a) A prospective drug use review (Pro-DUR)
				  that requires all pharmacy providers to:
(i)
				  Obtain patient histories of allergies, idiosyncrasies, or chronic condition or
				  conditions which may relate to drug utilization;
(ii) Screen for potential drug therapy
				  problems;
(iii) Counsel the patient
				  in accordance with existing state pharmacy laws and federal regulations;
				  and
(iv) Obtain authorization as
				  described in WAC
				  182-530-3200
				  prior to dispensing when required by the agency or an agency
				  designee.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › QUALITY OF CARE › Section 182-530-4100 - Medicaid preferred drug list (medicaid PDL)

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency contracts with a
				  vendor to perform systematic evidence-based drug reviews.
(2) The pharmacy and therapeutics (P&T)
				  committee or the drug use review (DUR) board reviews and evaluates the safety,
				  efficacy, and outcomes of prescribed drugs, using evidence-based drug
				  reviews.
(3) The P&T committee
				  makes recommendations to state agencies as to which drugs to include on the
				  Washington PDL under chapter 182-50 WAC. The DUR board makes recommendations to
				  the medicaid agency about which additional drug classes to include in the
				  medicaid PDL.
(4) The agency
				  director or des-ignee makes the final selection of drugs or drug classes
				  included on the medicaid PDL.
(5)
				  Drugs in a drug class on the medicaid PDL which are not on the Washington PDL
				  are not subject to therapeutic interchange program (TIP) and dispense as
				  written (DAW) rules under WAC
				  182-530-4150.
(6) Drugs in a drug class on the medicaid PDL
				  that have not been reviewed by the P&T committee or the DUR board may be
				  treated as nonpreferred drugs and are not subject to DAW or TIP.
(7) A nonpreferred drug is considered for
				  authorization after the client has:
(a) Tried
				  and failed or is intolerant to at least one preferred drug; and
(b) Met agency-established criteria for the
				  nonpreferred drug.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › QUALITY OF CARE › Section 182-530-4125 - Generics first for a client's first course of treatment

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency may require preferred generic drugs on the Washington preferred drug
				  list (Washington PD L) be use d b efo r e an y b r and nam e or nonpr e-ferred
				  generic drugs for a client's first course of treatment within that therapeutic
				  class of drugs, according to
				  RCW
				  69.41.190.
(2) For drug classes selected by the agency
				  that meet the criteria of subsection (1) of this section, only preferred
				  generic drugs are covered for a client's first course of treatment, except as
				  identified in subsection (3) of this section.
(3) Endorsing practitioners' prescriptions
				  written "dispense as written (DAW)" for preferred and nonpreferred brand name
				  drugs and nonpreferred generics in the specific drug classes on the Washington
				  PDL reviewed by the drug use review (DUR) board will be subject to
				  authorization to establish medical necessity as defined in WAC
				  182-500-0070.
(4) The agency uses point-of-sale (POS) claim
				  messaging to tell pharmacies to use a preferred generic drug for the client's
				  first course of treatment in specific drug classes.
11-14-075, recodified as §
												182-530-4125, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.04.050,
						74.09.700,
						74.08.090, 2009 c 575. 10-06-011,
						§ 388-530-4125, filed 2/19/10, effective
						3/22/10.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › QUALITY OF CARE › Section 182-530-4150 - Therapeutic interchange program (TIP)

Current through Register Vol. 24-14, July 15, 2024
This section contains the medicaid agency's rules for the
					 endorsing practitioner therapeutic interchange program (TIP). TIP is
					 established under
					 RCW
					 69.41.190 and
					 70.14.050.
(1) TIP applies only to drugs:
(a) Within therapeutic classes on the
				  Washington preferred drug list (Washington PDL);
(b) Included in a motion passed by the
				  pharmacy and therapeutics (P&T) committee; and
(c) Prescribed by an endorsing
				  practitioner.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › BILLING › Section 182-530-5000 - Billing requirements-Pharmacy claim payment

Current through Register Vol. 24-14, July 15, 2024
(1) When billing the medicaid agency for
				  pharmacy services, providers must:
(a) Use the
				  appropriate agency claim form or electronic billing specifications;
(b) Include the actual 11-digit national drug
				  code (NDC) number of the product dispensed from a rebate eligible
				  manufacturer;
(c) Bill the agency
				  using metric decimal quantities which is the National Council for Prescription
				  Drug Programs (NCPDP) billing unit standard;
(d) Meet the general provider documentation
				  and record retention requirements in WAC
				  182-502-0020; and
(e) Maintain proof of delivery receipts.
(i) When a provider delivers an item directly
				  to the client or the client's designee, the provider must be able to furnish
				  proof of delivery, including the signature of either the client, the client's
				  designee, or the provider, the client's name, and a detailed description of the
				  item or items delivered.
(ii) When
				  a provider mails an item to the client, the provider must be able to furnish
				  proof of delivery including a mail log.
(iii) When a provider uses a delivery or
				  shipping service to deliver items, the provider must be able to furnish proof
				  of delivery and it must:
(A) Include the
				  delivery service tracking slip with the client's name or a reference to the
				  client's package or packages; the delivery service package identification
				  number; and the delivery address.
(B) Include the supplier's shipping invoice,
				  with the client's name; the shipping service package identification number; and
				  a detailed description.
(iv) Make proof of delivery receipts
				  available to the agency upon request.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › BILLING › Section 182-530-5050 - Billing requirements - Point-of-sale (POS) system/prospective drug use review (Pro-DUR)

Current through Register Vol. 24-14, July 15, 2024
(1) Pharmacy claims
				  for drugs and other products listed in the medicaid agency's drug file and
				  billed to the agency by national drug code (NDC) are adjudicated by the
				  agency's point-of-sale (POS) system. Claims must be submitted for payment using
				  the billing unit standard identified in WAC
				  182-530-5000.
(2) All pharmacy drug claims processed
				  through the POS system undergo a system-facilitated prospective drug use review
				  (Pro-DUR) screening as a complement to the Pro-DUR screening required of
				  pharmacists.
(3) If the POS system
				  identifies a potential drug therapy problem during Pro-DUR screening, a message
				  will alert the pharmacy provider indicating the type of potential problem. The
				  alerts regarding possible drug therapy problems include, but are not limited
				  to:
(a) Therapeutic duplication;
(b) Duration of therapy exceeds the
				  recommended maximum period;
(c)
				  Drug-to-drug interaction;
(d) Drug
				  disease precaution;
(e) High
				  dose;
(f) Ingredient
				  duplication;
(g) Drug-to-client age
				  conflict;
(h) Drug-to-client gender
				  conflict; or
(i) Refill too
				  soon.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › BILLING › Section 182-530-5100 - Billing requirements - Unit dose

Current through Register Vol. 24-14, July 15, 2024
(1)
				  To be eligible for a unit dose dispensing fee from the medicaid agency, a
				  pharmacy must:
(a) Notify the agency in
				  writing of its intent to provide unit dose service;
(b) Identify the nursing facility or
				  facilities to be served;
(c)
				  Indicate the approximate date unit dose service to the facility or facilities
				  will commence; and
(d) Follow
				  agency requirements for unit dose payment.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT › Section 182-530-7000 - Reimbursement

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency's reimbursement for a prescription drug dispensed through point-of-sale
				  (POS) must not exceed the lesser of actual acquisition cost (AAC) plus a
				  professional dispensing fee or the provider's usual and customary
				  charge.
(2) The agency selects the
				  sources for pricing information used to set AAC.
(3) The AAC is calculated as the lowest of:
(a) National average drug acquisition cost
				  (NADAC);
(b) Maximum allowable cost
				  (MAC);
(c) Federal upper limit
				  (FUL);
(d) 340B MAC for covered
				  outpatient drugs purchased, dispensed, or administered under section 340B of
				  the Public Health Service (PHS) Act (see WAC
				  182-530-7900 for exceptions);
				  or
(e) Submitted ingredient
				  cost.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT › Section 182-530-7050 - Reimbursement-Dispensing fee determination

Current through Register Vol. 24-14, July 15, 2024
(1) Subject
				  to the provisions of WAC
				  182-530-7000 and the exceptions
				  permitted in WAC
				  182-530-2000, the medicaid agency
				  pays a dispensing fee for each covered, prescribed drug.
(2) The agency does not pay a dispensing fee
				  for:
(a) Nondrug items, devices, or
				  drug-related supplies; or
(b) Drugs
				  administered by a health care professional.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT › Section 182-530-7100 - Reimbursement - Pharmaceutical supplies

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency reimburses for
				  selected pharmaceutical supplies through the pharmacy point-of-sale (POS)
				  system when it is necessary for client access and safety.
(2) The agency bases reimbursement of
				  pharmaceutical items or supplies that are not payable through the POS on
				  agency-published fee schedules.
(3)
				  The agency uses any or all of the following methodologies to set the maximum
				  allowable reimbursement rate for drugs, devices, and drug-related supplies:
(a) A pharmacy provider's acquisition cost.
				  Upon review of the claim, the agency may require an invoice which must show the
				  name of the item, the manufacturer, the product description, the quantity, and
				  the current cost including any free goods associated with the
				  invoice;
(b) Medicare's
				  reimbursement rate for the item; or
(c) A specified discount off the item's list
				  price or manufacturer's suggested retail price (MSRP).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT › Section 182-530-7150 - Reimbursement-Compounded prescriptions

Current through Register Vol. 24-14, July 15, 2024
(1) The
				  medicaid agency does not consider reconstitution to be compounding.
(2) The agency covers a drug ingredient used
				  for a compounded prescription only when the manufacturer has a signed rebate
				  agreement with the federal Department of Health and Human Services
				  (DHHS).
(3) The agency considers
				  bulk chemical supplies used in compounded prescriptions as nondrug items, which
				  do not require a drug rebate agreement. The agency covers such bulk chemical
				  supplies only as specifically approved by the agency.
(4) The agency reimburses pharmacists for
				  compounding drugs only if the client's drug therapy needs are unable to be met
				  by commercially available dosage strengths or forms of the medically necessary
				  drug.
(a) The pharmacist must ensure the need
				  for the adjustment of the drug's therapeutic strength or form is
				  well-documented in the client's file.
(b) The pharmacist must ensure that the
				  ingredients used in a compounded prescription are for an approved use as
				  defined in "medically accepted indication" in WAC
				  182-530-1050.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT › Section 182-530-7200 - Reimbursement - Out-of-state prescriptions

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency reimburses
				  out-of-state pharmacies for prescription drugs provided to an eligible client
				  within the scope of the client's medical care program if the pharmacy:
(a) Contracts with the agency to be an
				  enrolled provider; and
(b) Meets
				  the same criteria the agency requires for in-state pharmacy
				  providers.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT › Section 182-530-7250 - Reimbursement-Miscellaneous

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency reimburses for covered drugs, devices, and drug-related supplies
				  provided or administered by nonpharmacy providers under specified conditions,
				  as follows:
(a) The agency reimburses for
				  drugs administered or prepared and delivered for individual use by an
				  authorized prescriber during an office visit according to specific program
				  rules found in:
(i) Chapter 182-531 WAC,
				  Physician-related services;
(ii)
				  Chapter 182-532 WAC, Reproductive health/family planning programs;
				  and
(iii) Chapter 182-540 WAC,
				  Kidney disease program and kidney center services.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT › Section 182-530-7300 - Reimbursement-Requesting a change

Current through Register Vol. 24-14, July 15, 2024
Upon request from a provider, the medicaid agency may
					 reimburse at the provider's actual acquisition cost AAC) for a drug that would
					 otherwise be reimbursed at maximum allowable cost (MAC) when:
(1) The availability of lower cost
				  equivalents in the marketplace is severely curtailed and the price disparity
				  between AAC for the drug and the MAC reimbursement affects clients' access;
				  and
(2) An invoice documenting AAC
				  relevant to the date the drug was dispensed is provided to the
				  agency.
11-14-075, recodified as §
												182-530-7300, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.04.050,
						74.08.090,
						74.09.530, and
						74.09.700. 07-20-049, §
						388-530-7300, filed 9/26/07, effective
						11/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT › Section 182-530-7350 - Reimbursement - Unit dose drug delivery systems

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency pays for unit dose
				  drug delivery systems only for clients residing in nursing facilities, except
				  as provided in subsections (7) and (8) of this section.
(2) Unit dose delivery systems may be either
				  true or modified unit dose.
(3) The
				  agency pays pharmacies that provide unit dose delivery services the agency's
				  highest allowable dispensing fee for each unit dose prescription dispensed to
				  clients in nursing facilities. The agency reimburses ingredient costs for drugs
				  under unit dose systems as described in WAC
				  182-530-7000.
(4) The agency pays a pharmacy that dispenses
				  drugs in bulk containers or multidose forms to clients in nursing facilities
				  the regular dispensing fee applicable to the pharmacy's total annual
				  prescription volume tier. Drugs the agency considers not deliverable in unit
				  dose form include, but are not limited to, liquids, creams, ointments,
				  ophthalmic and otic solutions. The agency reimburses ingredient costs as
				  described in WAC
				  182-530-7000.
(5) The agency pays a pharmacy that dispenses
				  drugs prepackaged by the manufacturer in unit dose form to clients in nursing
				  facilities the regular dispensing fee applicable under WAC
				  182-530-7050. The agency
				  reimburses ingredient costs for drugs prepackaged by the manufacturer in unit
				  dose form as described in WAC
				  182-530-7000.
(6) The agency limits its coverage and
				  payment for manufacturer-designated unit dose packaging to the following
				  conditions:
(a) The drug is a single source
				  drug and a multidose package for the drug is not available;
(b) The drug is a multiple source drug but
				  there is no other multidose package available among the drug's generic
				  equivalents; or
(c) The
				  manufacturer-designated unit dose package is the most cost-effective package
				  available or it is the least costly alternative form of the drug.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT › Section 182-530-7400 - Reimbursement - Compliance packaging services

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency reimburses pharmacies
				  for compliance packaging services provided to clients considered at risk for
				  adverse drug therapy outcomes. Clients who are eligible for compliance
				  packaging services must not reside in a nursing home or other inpatient
				  facility, and must meet (a) and either (b) or (c) of this subsection. The
				  client must:
(a) Have one or more of the
				  following representative disease conditions:
(i) Alzheimer's disease;
(ii) Blood clotting disorders;
(iii) Cardiac arrhythmia;
(iv) Congestive heart failure;
(v) Depression;
(vi) Diabetes;
(vii) Epilepsy;
(viii) HIV/AIDS;
(ix) Hypertension;
(x) Schizophrenia; or
(xi) Tuberculosis.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT › Section 182-530-7500 - Drug rebate requirement

Current through Register Vol. 24-14, July 15, 2024
(1)
				  The medicaid agency reimburses for outpatient prescription drugs only when they
				  are supplied by manufacturers who have a signed drug rebate agreement with the
				  federal Department of Health and Human Services (DHHS), according to
				  42 U.S.C.
				  1396r-8. The manufacturer must be listed on
				  the list of participating manufacturers as published by the Center for Medicare
				  and Medicaid Services (CMS).
(2)
				  The fill date must be within the manufacturer's beginning and ending
				  eligibility dates to be reimbursed by the agency.
(3) The agency may extend this rebate
				  requirement to any outpatient drug reimbursements as allowed or required by
				  federal law.
(4) The agency may
				  exempt drugs from the rebate requirement, on a case-by-case basis, when:
(a) It determines that the availability of a
				  single source drug or innovator multiple source drug is essential to the health
				  of beneficiaries; and
(b) All other
				  rebate exemption requirements of SSA Sec. 1927 (
				  42 U.S.C.
				  1396r-8 )(3) are also satisfied.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT › Section 182-530-7600 - Reimbursement - Clients enrolled in managed care

Current through Register Vol. 24-14, July 15, 2024
Except as specified under the medicaid agency's managed
					 care contracts, the agency does not reimburse providers for any drugs or
					 pharmaceutical supplies provided to clients who have pharmacy benefits under
					 agency-contracted managed care plans. The managed care plan is responsible for
					 payment.
11-14-075, recodified as §
												182-530-7600, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.04.050,
						74.08.090,
						74.09.530, and
						74.09.700. 07-20-049, §
						388-530-7600, filed 9/26/07, effective
						11/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT › Section 182-530-7700 - Reimbursement-Dual eligible clients/medicare

Current through Register Vol. 24-14, July 15, 2024
For clients who are dually eligible for medical assistance
					 and medicare benefits, the following applies:
(1) The agency pays medicare coinsurance,
				  copayments, and deductibles for Part A, Part B, and medicare advantage Part C,
				  subject to the limitations in WAC
				  182-502-0110.
(2) Medicare Part D:
(a) Medicare is the payer for drugs included
				  in the medicare Part D benefit.
(b)
				  The agency does not pay for Part D drugs or Part D copayments.
(c) For drugs excluded from the medicare Part
				  D benefit:
(i) The agency offers the same drug
				  benefit as a nondual eligible client has within those same classes;
(ii) If the client has another third party
				  insurer, that insurer is the primary payer; and
(iii) The agency is the payer of last
				  resort.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT › Section 182-530-7800 - Reimbursement - Clients with third-party liability

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency requires providers to
				  meet the third-party requirements of WAC
				  182-501-0200.
(2) The following definitions apply to this
				  section:
(a) "Closed pharmacy network" means
				  an arrangement made by an insurer which restricts prescription coverage to an
				  exclusive list of pharmacies. This arrangement prohibits the coverage and/or
				  payment of prescriptions provided by a pharmacy that is not included on the
				  exclusive list.
(b) "Private
				  point-of-sale (POS) authorization system" means an insurer's system, other than
				  the agency's POS system, which requires that coverage be verified by or
				  submitted to the insurer for authorization at the time of service and at the
				  time the prescription is filled.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT › Section 182-530-7900 - Drugs purchased under the Public Health Service (PHS) Act

Current through Register Vol. 24-14, July 15, 2024
(1) Providers
				  registered and approved as PHS-qualified covered entities participate in the
				  340B program under their medicaid provider number or NPI listed on the
				  quarterly medicaid exclusion file (MEF).
(2) PHS-qualified covered entities
				  participating in the 340B program must follow federal and state 340B program
				  requirements and applicable medicaid agency rules including, but not limited
				  to, this chapter, chapters 182-501 and 182-502 WAC, and agency billing
				  instructions.
(3) All claims
				  submitted to Washington apple health through fee-for-service (FFS) or managed
				  care for outpatient drugs purchased, dispensed, or administered by
				  PHS-qualified covered entities participating in the 340B program:
(a) May be billed only by the PHS-qualified
				  covered entity participating in the 340B program under their participating
				  medicaid provider number or NPI listed in the quarterly medicaid exclusion
				  file; and
(b) Are excluded from
				  medicaid drug rebate invoicing. See WAC
				  182-530-7500 for information on
				  the drug rebate program.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT METHODOLOGY › Section 182-530-8000 - Reimbursement method-Actual acquisition cost (AAC)

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency uses the following sources to determine
					 actual acquisition cost AAC) including, but not limited to:
(1) National average drug acquisition cost
				  (NADAC) published by the Centers for Medicare and Medicaid Services
				  (CMS);
(2) Acquisition cost data
				  made available to the agency by:
(a) Audit
				  results from federal or state agencies;
(b) Other state health care purchasing
				  organizations;
(c) Pharmacy benefit
				  managers;
(d) Individual pharmacy
				  providers participating in the agency's programs;
(e) Other third-party payers;
(f) Drug file databases; and
(g) Actuaries or other consultants.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT METHODOLOGY › Section 182-530-8050 - Reimbursement - Federal upper limit (FUL)

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency adopts the federal
				  upper limit (FUL) set by the Centers for Medicare and Medicaid Services
				  (CMS).
(2) The agency's maximum
				  payment for multiple-source drugs for which CMS has set FULs will not exceed,
				  in the aggregate, the prescribed upper limits plus the dispensing fees set by
				  the agency.
(3) Except as provided
				  in WAC 182-530-7300, the agency uses the
				  FUL as the agency's reimbursement rate for the drug when the FUL price is the
				  lowest of the rates calculated under the methods listed in WAC
				  182-530-7000.
11-14-075, recodified as §
												182-530-8050, filed 6/30/11,
						effective 7/1/11. Statutory Authority:
						RCW
						74.04.050,
						74.08.090,
						74.09.530, and
						74.09.700. 07-20-049, §
						388-530-8050, filed 9/26/07, effective
						11/1/07.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT METHODOLOGY › Section 182-530-8100 - Reimbursement-Maximum allowable cost (MAC)

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				  agency establishes a maximum allowable cost (MAC) for covered outpatient
				  drugs.
(2) The agency determines
				  the MAC for covered outpatient drugs:
(a) When
				  specific regional and local drug acquisition cost data is available, the
				  agency:
(i) Identifies what products are
				  available from wholesalers for each drug being considered for MAC
				  pricing;
(ii) Determines pharmacy
				  providers' approximate acquisition costs for these products; and
(iii) Establishes the MAC at a level which
				  gives pharmacists access to at least one product from a manufacturer with a
				  qualified rebate agreement (see WAC
				  182-530-7500(4)).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-530 - Prescription drugs (outpatient) › REIMBURSEMENT METHODOLOGY › Section 182-530-8150 - Reimbursement-Automated maximum allowable cost (AMAC)

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency uses the automated
				  maximum allowable cost (AMAC) pricing methodology for multiple-source drugs
				  that are:
(a) Not on the published maximum
				  allowable cost (MAC); and
(b)
				  Produced by two or more manufacturers/labelers, at least one of which must have
				  a current, signed federal drug rebate agreement.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0100 - Scope of coverage for physician-related and health care professional services-General and administrative

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency covers health care services, equipment, and supplies listed in this
				chapter, according to agency rules and subject to the limitations and
				requirements in this chapter, when they are:
(a) Within the scope of an eligible client's
				Washington apple health program. Refer to WAC
				182-501-0060 and
				182-501-0065; and
(b) Medically necessary as defined in WAC
				182-500-0070.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0200 - Physician-related and health care professional services requiring prior authorization

Current through Register Vol. 24-14, July 15, 2024
(1) The
				medicaid agency requires
prior authorization
for certain services.
				Prior authorization includes
expedited prior authorization (EPA)
and
limitation extension (LE).
See WAC
				182-501-0165.
(2) EPA is designed to eliminate the need for
				written authorization. The agency establishes authorization criteria and
				identifies the criteria with specific codes, enabling providers to use that EPA
				number if a client meets the EPA criteria.
(a)
				The provider must create an authorization number using the process explained in
				the medicaid agency's physician-related billing instructions.
(b) Upon request, the provider must provide
				supporting clinical documentation to the medicaid agency showing how the
				authorization number was created.
(c) Selected nonemergency admissions to
				contract hospitals require EPA. These are identified in the medicaid agency
				billing instructions.
(d)
				Procedures allowing expedited prior authorization include, but are not limited
				to, the following:
(i) Reduction
				mammoplasties/mastectomy for gynecomastia;
(ii) Strabismus surgery for clients 18 years
				of age and older;
(iii)
				Meningococcal vaccine;
(iv)
				Placement of drug eluting stent and device;
(v) Cochlear implant devices;
(vi) Hyperbaric oxygen therapy;
(vii) Visual exam/refraction for clients 21
				years of age and older;
(viii)
				Blepharoplasties; and
(ix)
				Neuropsychological testing for clients 16 years of age and older.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0250 - Who can provide and bill for physician-related and health care professional services

Current through Register Vol. 24-14, July 15, 2024
(1) The health care
				professionals and health care entities listed in WAC
				182-502-0002 and enrolled with
				the medicaid agency can bill for physician-related and health care professional
				services that are within their scope of practice.
(2) The agency pays for services provided by,
				or in conjunction with, a resident physician when:
(a) The services are billed under the
				teaching hospital's national provider identifier (NPI) or the supervising
				physician's NPI;
(b) The servicing
				provider is identified on the claim under the teaching or resident physician's
				NPI; and
(c) The services are
				provided and billed according to this chapter and chapters 182-501 and 182-502
				WAC.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0300 - Anesthesia providers and covered physician-related services

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency bases coverage of anesthesia services on
				  medicare policies and the following rules:
(1) The agency reimburses providers for
				covered anesthesia services performed by:
(a)
				Anesthesiologists;
(b) A doctor of
				medicine or osteopathy (other than an anesthesiologist);
(c) Certified registered nurse anesthetists
				(CRNAs);
(d) Oral surgeons with a
				special agreement with the agency to provide anesthesia services; and
(e) Other providers who have a special
				agreement with the agency to provide anesthesia services.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0350 - Anesthesia services - Reimbursement for physician-related services

Current through Register Vol. 24-14, July 15, 2024
(1) The department
				reimburses anesthesia services on the basis of base anesthesia units (BAU) plus
				time.
(2) The department calculates
				payment for anesthesia by adding the BAU to the time units and multiplying that
				sum by the conversion factor. The formula used in the calculation is: (BAU x
				fifteen) + time) x (conversion factor divided by fifteen) =
				reimbursement.
(3) The department
				obtains BAU values from the relative value guide
(RVG)
, and
				updates them annually. The department and/or the anesthesia technical advisory
				group
(ATAG)
members establish the base units for procedures for
				which anesthesia is appropriate but do not have BAUs established by RVSP and
				are not defined as add-on.
(4) The
				department determines a budget neutral anesthesia conversion factor by:
(a) Determining the BAUs, time units, and
				expenditures for a
base period
for the provided procedure.
				Then,
(b) Adding the latest BAU
				RVSP to the time units for the base period to obtain an estimate of the new
				time unit for the procedure. Then,
(c) Multiplying the time units obtained in
				(b) of this subsection for the new period by a conversion factor to obtain
				estimated expenditures. Then,
(d)
				Comparing the expenditures obtained in (c) of this subsection with base period
				expenditure levels obtained in (a) of this subsection. Then,
(e) Adjusting the dollar amount for the
				anesthesia conversion factor and the projected time units at the new BAUs
				equals the allocated amount determined in (a) of this subsection.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0375 - Audiology services

Current through Register Vol. 24-14, July 15, 2024
(1) The agency
				covers medically necessary cochlear implant devices with prior authorization
				for eligible clients.
(2) The
				agency covers BAHAs for clients 20 years of age and younger with prior
				authorization.
(3) The agency
				covers replacement parts and batteries for BAHAs and cochlear implant devices.
				See WAC 182-547-0800 and
				182-547-0850.
(4) The agency considers requests for removal
				or repair of previously implanted BAHAs and cochlear implant devices when
				medically necessary. Prior authorization from the agency is required.
11-14-075, recodified as §
											182-531-0375, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090. 11-14-055, § 388-531-0375,
					 filed 6/29/11, effective 7/30/11.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0400 - Client responsibility for reimbursement for physician-related services

Current through Register Vol. 24-14, July 15, 2024
Clients may be responsible to reimburse the provider, as
				  described under WAC
				  182-501-0100, for noncovered
				  services as defined in WAC
				  182-501-0050 or for services
				  excluded from the client's benefits package as defined under WAC
				  182-501-0060. Clients whose care
				  is provided under CHIP may be responsible for copayments as outlined in chapter
				  182-542 WAC. Also, see WAC
				  182-502-0160 Billing the
				  client.
11-14-075, recodified as §
											182-531-0400, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090. 11-14-055, § 388-531-0400,
					 filed 6/29/11, effective 7/30/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.520. 01-01-012, §
					 388-531-0400, filed 12/6/00, effective
					 1/6/01.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0425 - Collaborative care

Current through Register Vol. 24-14, July 15, 2024
(1) Under the
				authority of
				RCW
				74.09.497, and subject to available funds,
				the medicaid agency covers collaborative care provided in clinical care
				settings.
(2) For the purposes of
				this section:
(a)
Collaborative
				care
means a specific type of integrated care where medical providers
				and behavioral health providers work together to address behavioral health
				conditions, including mental health conditions and substance use
				disorders.
(b)
Collaborative
				care model
is a model of behavior health integration that enhances usual
				clinical care by adding two key services:
(i)
				Care management support for clients receiving behavioral health treatment;
				and
(ii) Regular psychiatric or
				board certified addiction medicine consultation with the clinical care team,
				particularly for clients whose conditions are not improving.
(c)
Collaborative care
				team
means a team of licensed behavioral health professionals operating
				within their scope of practice who participate on the clinical care team along
				with the collaborative care billing provider to provide collaborative care to
				eligible clients. The team must include a collaborative care billing provider,
				a behavioral health care manager, and a psychiatric consultant. Professionals
				making up this team include, but are not limited to:
(i) Advanced registered nurses;
(ii) Substance use disorder professionals
				(SUDP);
(iii) Substance use
				disorder professional trainees (SUDPT) under the supervision of a certified
				SUDP;
(iv) Marriage and family
				therapists;
(v) Marriage and family
				therapist associates under the supervision of a licensed marriage and family
				therapist or equally qualified mental health practitioner;
(vi) Mental health counselors;
(vii) Mental health counselor associates
				under the supervision of a licensed mental health counselor, psychiatrist, or
				physician;
(viii)
				Physicians;
(ix) Physician
				assistants under the supervision of a licensed physician;
(x) Psychiatrists;
(xi) Psychiatric advanced registered
				nurses;
(xii)
				Psychologists;
(xiii) Registered
				nurses;
(xiv) Social
				workers;
(xv) Social worker
				associate-independent clinical, under the supervision of a licensed independent
				clinical social worker or equally qualified mental health practitioner;
				and
(xvi) Social worker
				associate-advanced, under the supervision of a licensed independent clinical
				social worker, advanced social worker, or equally qualified mental health
				practitioner.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0450 - Critical care - Physician-related services

Current through Register Vol. 24-14, July 15, 2024
(1) The department reimburses the following
				physicians for critical care services:
(a)
				The attending physician who assumes responsibility for the care of a client
				during a life-threatening episode;
(b) More than one physician if the services
				provided involve multiple organ systems; or
(c) Only one physician for services provided
				in the emergency room.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0500 - Emergency physician-related services

Current through Register Vol. 24-14, July 15, 2024
(1) The department reimburses for E&M
				services provided in the hospital emergency department to clients who arrive
				for immediate medical attention.
(2) The department reimburses emergency
				physician services only when provided by physicians assigned to the hospital
				emergency department or the physicians on
call
to cover the
				hospital emergency department.
(3)
				The department pays a provider who is called back to the emergency room at a
				different time on the same day to attend a return visit [to] the same client.
				When this results in multiple claims on the same day, the time of each
				encounter must be clearly indicated on the claim.
(4) The department does not pay emergency
				room physicians for
hospital admission
charges or additional
				service charges.
11-14-075, recodified as §
											182-531-0500, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090. 10-19-057, § 388-531-0500,
					 filed 9/14/10, effective 10/15/10. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.520. 01-01-012, §
					 388-531-0500, filed 12/6/00, effective
					 1/6/01.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0550 - Experimental and investigational services

Current through Register Vol. 24-14, July 15, 2024
(1) When the department makes a determination
				as to whether a proposed service is experimental or investigational, the
				department follows the procedures in this section. The policies and procedures
				and any criteria for making decisions are available upon request.
(2) The determination of whether a service is
				experimental and/or investigational is subject to a case-by-case review under
				the provisions of WAC 388-501-0165 which relate to medical necessity. The
				department also considers the following:
(a)
				Evidence in
peer-reviewed medical literature
, as defined in WAC
				388-531-0050, and preclinical and clinical data reported to the National
				Institute of Health and/or the National Cancer Institute, concerning the
				probability of the service maintaining or significantly improving the
				enrollee's length or quality of life, or ability to function, and whether the
				benefits of the service or treatment are outweighed by the risks of death or
				serious complications;
(b) Whether
				evidence indicates the service or treatment is more likely than not to be as
				beneficial as existing conventional treatment alternatives for the treatment of
				the condition in question;
(c)
				Whether the service or treatment is generally used or generally accepted for
				treatment of the condition in the United States;
(d) Whether the service or treatment is under
				continuing scientific testing and research;
(e) Whether the service or treatment shows a
				demonstrable benefit for the condition;
(f) Whether the service or treatment is safe
				and efficacious;
(g) Whether the
				service or treatment will result in greater benefits for the condition than
				another generally available service; and
(h) If approval is required by a regulating
				agency, such as the Food and Drug Administration, whether such approval has
				been given before the date of service.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-531 - Physician-related services › Section 182-531-0600 - HIV/AIDS counseling and testing as physician-related services

Current through Register Vol. 24-14, July 15, 2024
The department covers one pre- and one post-HIV/AIDS
				  counseling/testing session per client each time the client is tested for
				  HIV/AIDS.
11-14-075, recodified as §
											182-531-0600, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090. 10-19-057, § 388-531-0600,
					 filed 9/14/10, effective 10/15/10. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.520. 01-01-012, §
					 388-531-0600, filed 12/6/00, effective
					 1/6/01.