reglab/statecodes huggingface dataset:
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-547 - Hearing aids › Section 182-547-0800 - Coverage - Clients age twenty years and younger

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency covers new,
				nonrefurbished, monaural or binaural hearing aid(s), which includes the ear
				molds, for eligible clients age twenty and younger. In order for the provider
				to receive payment, the hearing aid must meet the client's specific hearing
				needs and carry a manufacturer's warranty for a minimum of one year.
(2) The agency pays for the following
				replacements as long as the need for replacement is not due to the client's
				carelessness, negligence, recklessness, deliberate intent, or misuse in
				accordance with WAC
				182-501-0050:
(a) Hearing aid(s), which includes the ear
				molds, when:
(i) The client's hearing aid(s)
				are:
(A) Lost;
(B) Beyond repair; or
(C) Not sufficient for the client's hearing
				loss; and
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-547 - Hearing aids › Section 182-547-0850 - Coverage-Clients age twenty-one and older

Current through Register Vol. 24-14, July 15, 2024
(1)
Nonrefurbished, monaural hearing
				aids.
The medicaid agency covers one new nonrefurbished monaural hearing
				aid, which includes the ear mold, every five years for clients age twenty-one
				and older.
(a) The client must have an
				average decibel loss of forty-five or greater in the better ear, based on a
				pure-tone audio-metric evaluation by a licensed audiologist or a licensed
				hearing aid specialist at 1000, 2000, 3000, and 4000 hertz (Hz) with effective
				masking as indicated.
(b) The
				hearing aid must meet the client's specific hearing needs and carry a
				manufacturer's warranty for a minimum of one year.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-547 - Hearing aids › Section 182-547-0900 - Noncovered services-Clients age twenty-one and older

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency does not cover the
				following items:
(a) Tinnitus
				maskers;
(b) Frequency modulation
				(FM) systems, including the computer-aided hearing devices for FM systems;
				and
(c) Nonprescription hearing
				aids or similar devices including, but not limited to:
(i) Personal sound amplification products
				(PSAPs);
(ii) Hearables;
				and
(iii) Pocket talkers or similar
				devices.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-547 - Hearing aids › Section 182-547-1000 - Prior authorization-Clients age twenty and younger

Current through Register Vol. 24-14, July 15, 2024
(1) Prior authorization is not required for
				clients age twenty and younger for hearing aid(s) and services.
(2) The agency pays for services according to
				the early and periodic screening, diagnostic, and treatment (EPSDT) provisions,
				as described in chapter 182-534 WAC. The standard for coverage for EPSDT is
				that services, treatment, or other measures are medically necessary, safe and
				effective, and not experimental.
(3) When billing, providers must send claims
				for clients age twenty and younger directly to the medicaid agency. Providers
				do not have to obtain authorization from the local children with special health
				care needs (CSHCN) coordinator.
Statutory
				  Authority:
				  RCW
				  41.05.021. WSR 13-20-013, 182-547-1000, filed
				  9/20/13, effective 10/21/13. WSR 11-14-075, recodified as 182-547-1000, filed
				  6/30/11, effective 7/1/11. Statutory Authority:
				  RCW
				  74.08.090 and
				  74.09.530. WSR 09-12-034,
				  388-547-1000, filed 5/27/09, effective 7/1/09. WSR 13-20-001, §
										182-547-1000, filed 9/18/2013,
				  effective 10/19/2013
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-547 - Hearing aids › Section 182-547-1050 - Prior authorization-Clients age twenty-one and older

Current through Register Vol. 24-14, July 15, 2024
(1) The agency
				requires prior authorization for covered hearing aids when the clinical
				criteria set forth in this chapter are not met. The agency evaluates these
				requests on a case-by-case basis to determine whether they are medically
				necessary, according to the process found in WAC
				182-501-0165.
(2) For covered services that require prior
				authorization (PA), the provider must properly request authorization in
				accordance with the medicaid agency's rules and billing instructions.
(3) The agency evaluates requests for covered
				services that are subject to limitations or other restrictions and considers
				such services beyond those limitations or restrictions as described in WAC
				182-501-0169.
(4) When the agency authorizes hearing aids
				or hearing aid-related services, the PA indicates only that the specific
				service is medically necessary; it is not a guarantee of payment. The client
				must be eligible for covered services at the time those services are provided.
(5) To receive payment, providers
				must order and dispense hearing aids and hearing aid-related services within
				the authorized time frame.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-547 - Hearing aids › Section 182-547-1100 - Reimbursement

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency's payment for purchased hearing aids includes all of the following:
(a) The audiometric evaluation;
(b) An impression for an ear mold;
(c) The ear mold;
(d) The dispensing fee;
(e) A conformity evaluation, if
				done;
(f) Three batteries;
				and
(g) Up to three follow-up
				visits for the fitting, orientation, and checking of the hearing aid.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-548 - Federally qualified health centers › Section 182-548-1000 - Federally qualified health centers-Purpose

Current through Register Vol. 24-14, July 15, 2024
This chapter establishes the medicaid agency's:
(1)Requirements for enrollment as a federally
				qualified health center (FQHC) provider; and
(2) Reimbursement methodology for services
				provided by an FQHC to a Washington apple health client.
11-14-075, recodified as §
											182-548-1000, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090, BIPA of 2000 Section 702, sections
					 201 and 209 of 2009-2011 budget bill, and
					 42 U.S.C.
					 1396 a(bb). 10-09-002, § 388-548-1000,
					 filed 4/7/10, effective 5/8/10.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-548 - Federally qualified health centers › Section 182-548-1200 - Federally qualified health centers-Enrollment

Current through Register Vol. 24-14, July 15, 2024
(1) To enroll as a
				Washington apple health provider and receive payment for services, a federally
				qualified health center (FQHC) must:
(a)
				Receive FQHC certification for participation in the Title XVIII (medicare)
				program according to 42 C.F.R. 491;
(b) Sign a core provider agreement with the
				medicaid agency; and
(c) Operate in
				accordance with applicable federal, state, and local laws.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-548 - Federally qualified health centers › Section 182-548-1300 - Federally qualified health centers-Services

Current through Register Vol. 24-14, July 15, 2024
(1) The following
				outpatient services qualify for FQHC encounter rate reimbursement:
(a) Physician services specified in
				42 C.F.R.
				405.2412.
(b) Nurse practitioner or physician assistant
				services specified in
				42
				C.F.R. 405.2414.
(c) Clinical psychologist and clinical social
				worker services specified in
				42 C.F.R.
				405.2450.
(d) Visiting nurse services specified in
				42 C.F.R.
				405.2416.
(e) Nurse-midwife services specified in
				42 C.F.R.
				405.2401.
(f) Preventive primary services specified in
				42 C.F.R.
				405.2448.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-548 - Federally qualified health centers › Section 182-548-1400 - Federally qualified health centers-Payment methodologies

Current through Register Vol. 24-14, July 15, 2024
(1) For services
				provided during the period beginning January 1, 2001, and ending December 31,
				2008, the medicaid agency's payment methodology for federally qualified health
				centers (FQHC) was a prospective payment system (PPS) as authorized by
				42 U.S.C.
				1396a(bb)(2) and
				(3).
(2) For services provided beginning January
				1, 2009, FQHCs have the choice to be reimbursed under the PPS or to be
				reimbursed under an alternative payment methodology (APM), as authorized by
				42 U.S.C.
				1396a(bb)(6). As required by
				42 U.S.C.
				1396a(bb)(6), payments made
				under the APM are at least as much as payments that would have been made under
				the PPS.
(3) The agency calculates
				FQHC PPS encounter rates as follows:
(a)
				Until an FQHC's first audited medicaid cost report is available, the agency
				pays an average encounter rate of other similar FQHCs within the state,
				otherwise known as an interim rate.
(b) Upon availability of the FQHC's first
				audited medicaid cost report, the agency sets FQHC encounter rates at 100
				percent of its total reasonable costs as defined in the cost report. FQHCs
				receive this rate for the remainder of the calendar year during which the
				audited cost report became available. The encounter rate is then adjusted each
				January 1st by the percent change in the medicare economic index
				(MEI).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-548 - Federally qualified health centers › Section 182-548-1450 - Federally qualified health centers-General payment information

Current through Register Vol. 24-14, July 15, 2024
(1) The agency
				limits FQHC encounter rate reimbursement to one per client, per day except in
				the following circumstances:
(a) There is a
				subsequent visit in the same cost center that requires separate evaluation and
				treatment on the same day for unrelated diagnoses; or
(b) There are separate visits in different
				types of cost centers that occur with different health care professionals. (For
				example, a client with a separate medical and dental visit on the same
				day.)
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-548 - Federally qualified health centers › Section 182-548-1500 - Federally qualified health centers-Change in scope of service rate adjustment

Current through Register Vol. 24-14, July 15, 2024
In accordance with
				  42 U.S.C.
				  1396a(bb)(3)(B), the agency
				  adjusts its payment rate to a federally qualified health center (FQHC) to take
				  into account any increase or decrease in the scope of the FQHC's services. The
				  procedures and requirements for any such rate adjustment are described
				  below.
(1)
Triggering
				events.
(a) An FQHC may file a change
				in scope of services rate adjustment application with the agency on its own
				initiative only when the FQHC satisfies the criteria described in (a)(i), (ii),
				and (iii) of this subsection.
(i) When the
				cost to the FQHC of providing covered health care services to eligible clients
				has increased or decreased due to one or more of the following triggering
				events:
(A) A change in the type of health
				care services the FQHC provides;
(B) A change in the intensity of health care
				services the FQHC provides. Intensity means the total quantity of labor and
				materials consumed by an individual client during an average encounter has
				increased;
(C) A change in the
				duration of health care services the FQHC provides. Duration means the length
				of an average encounter has increased;
(D) A change in the amount of health care
				services the FQHC provides in an average encounter;
(E) Any change comparable to (a)(i)(A)
				through (D) of this subsection in which the type, intensity, duration or amount
				of services has decreased and the cost of an average encounter has
				decreased.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-548 - Federally qualified health centers › Section 182-548-1600 - Federally qualified health centers-Appeals related to overpayments

Current through Register Vol. 24-14, July 15, 2024
An overpayment assessment by the agency against an FQHC
				  identified in the annual managed care reconciliation (see WAC
				  182-548-1450)
				  may be appealed based on WAC
				  182-502-0230
				  and
				  RCW
				  41.05A.170. Administrative hearing appeals
				  are governed by chapter 34.05 RCW (Administrative Procedure Act) and chapter
				  182-526 WAC (HCA administrative hearing rules).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-548 - Federally qualified health centers › Section 182-548-1650 - Federally qualified health centers-Appeals related to rate setting

Current through Register Vol. 24-14, July 15, 2024
(1) An FQHC
				provider has a right to an administrative appeal of agency action related to
				rate setting under this chapter based on the rules in this section.
(a) The rules in WAC
				182-502-0220
				do not apply to appeals of agency action related to rate setting under this
				chapter.
(b) Appeals related to
				rate setting under this section are not governed by the Administrative
				Procedure Act, chapter 34.05 RCW.
(c) Any rate change that the agency grants
				that is the result of fraudulent practices on the part of the FQHC, including
				as described under
				RCW
				74.09.210, is exempt from the appeal
				provisions in this chapter.
(d) An
				FQHC who fails to submit requested information as outlined in this chapter will
				be determined to have abandoned their appeal.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-549 - Rural health clinics › Section 182-549-1000 - Rural health clinics-Purpose

Current through Register Vol. 24-14, July 15, 2024
This chapter establishes the medicaid agency's reimbursement
				  methodology for rural health clinic (RHC) services. RHC conditions for
				  certification are found in 42 C.F.R. Part 491.
11-14-075, recodified as §
											182-549-1000, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.510,
					 74.09.522,
					 42 C.F.R.
					 405.2472, 42 C.F.R. 491. 08-05-011, §
					 388-549-1000, filed 2/7/08, effective
					 3/9/08.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-549 - Rural health clinics › Section 182-549-1200 - Rural health clinics-Enrollment

Current through Register Vol. 24-14, July 15, 2024
(1) To participate
				in the Title XIX (medicaid) program or the Title XXI (CHIP) program and receive
				payment for services, a rural health clinic (RHC) must:
(a) Receive RHC certification for
				participation in the Title XVIII (medicare) program according to 42 C.F.R.
				491;
(b) Sign a core provider
				agreement with the medicaid agency;
(c) Comply with the clinical laboratory
				improvement amendments (CLIA) of 1988 testing for all laboratory sites per 42
				C.F.R. Part 493; and
(d) Operate in
				accordance with applicable federal, state, and local laws.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-549 - Rural health clinics › Section 182-549-1300 - Rural health clinics-Services

Current through Register Vol. 24-14, July 15, 2024
(1) Rural health
				clinic (RHC) services are defined under
				42
				C.F.R. 440.20(b).
(2) The medicaid agency pays for RHC services
				when they are:
(a) Within the scope of an
				encounter-eligible client's benefit package. See WAC
				182-501-0060;
				and
(b) Medically necessary as
				defined in WAC
				182-500-0070.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-549 - Rural health clinics › Section 182-549-1400 - Rural health clinics-Reimbursement and limitations

Current through Register Vol. 24-14, July 15, 2024
(1) For services
				provided during the period beginning January 1, 2001, and ending December 31,
				2008, the medicaid agency's payment methodology for rural health clinics (RHC)
				was a prospective payment system (PPS) as authorized by
				42 U.S.C.
				1396a(bb)(2) and
				(3).
(2) For services provided beginning January
				1, 2009, RHCs have the choice to be reimbursed under the PPS or be reimbursed
				under an alternative payment methodology (APM), as authorized by
				42 U.S.C.
				1396a(bb)(6). As required by
				42 U.S.C.
				1396a(bb)(6), payments made
				under the APM are at least as much as payments that would have been made under
				the PPS.
(3) The agency calculates
				RHC PPS encounter rates for RHC core services as follows:
(a) Until an RHC submits its first audited or
				as filed medicare cost report to the agency, the agency pays the RHC an average
				encounter rate of other similar RHCs within the state, otherwise known as an
				interim rate. Similar RHCs are defined as either all hospital based or all
				free-standing RHCs.
(b) Upon the
				RHC's request to the agency, which must include the submission of the RHC's
				first as filed or audited medicare cost report, the agency calculates the RHC's
				PPS rates for RHC core services. The agency sets each RHC's encounter rates by
				dividing 100 percent of the RHC's costs divided by the total number of RHC
				encounters reported in the submitted cost report. The encounter rate is
				effective on the date the agency receives the submitted medicare cost report
				from the RHC.
(c) RHCs receive this
				rate for the remainder of the calendar year during which the submitted medicare
				cost report became available to the agency. The agency then adjusts the
				encounter rate each January 1st by the percent change in the medicare economic
				index (MEI).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-549 - Rural health clinics › Section 182-549-1450 - Rural health clinics-General payment information

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency limits RHC encounter rate reimbursement to one per client, per day
				except in the following circumstances:
(a)
				There is a subsequent visit in the same cost center that requires separate
				evaluation and treatment on the same day for unrelated diagnoses; or
(b) There are separate visits in different
				types of cost centers that occur with different health care professionals. (For
				example, a client with a separate medical and dental visit on the same
				day.)
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-549 - Rural health clinics › Section 182-549-1500 - Rural health clinics-Change in scope of service rate adjustment

Current through Register Vol. 24-14, July 15, 2024
In accordance with
				  42 U.S.C.
				  1396a(bb)(3)(B), the agency
				  adjusts its payment rate to a rural health clinic (RHC) to take into account
				  any increase or decrease in the scope of the RHC's services. The procedures and
				  requirements for any such rate adjustment are described below.
(1)
Triggering events.
(a) An RHC may file a change in scope of
				services rate adjustment application with the agency on its own initiative only
				when the RHC satisfies the criteria described in (a)(i), (ii), and (iii) of
				this subsection.
(i) When the cost to the RHC
				of providing covered health care services to eligible clients has increased or
				decreased due to one or more of the following triggering events:
(A) A change in the type of health care
				services the RHC provides;
(B) A
				change in the intensity of health care services the RHC provides. Intensity
				means the total quantity of labor and materials consumed by an individual
				client during an average encounter has increased;
(C) A change in the duration of health care
				services the RHC provides. Duration means the length of an average encounter
				has increased;
(D) A change in the
				amount of health care services the RHC provides in an average
				encounter;
(E) Any change
				comparable to (a)(i)(A) through (D) of this subsection in which the type,
				intensity, duration or amount of services has decreased and the cost of an
				average encounter has decreased.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-549 - Rural health clinics › Section 182-549-1600 - Rural health clinics-Appeals related to overpayments

Current through Register Vol. 24-14, July 15, 2024
An overpayment assessment by the agency against an RHC that
				  was identified in the annual managed care reconciliation (see WAC
				  182-549-1450)
				  may be appealed based on WAC
				  182-502-0230
				  and
				  RCW
				  41.05A.170. Administrative hearing appeals
				  are governed by chapter 34.05 RCW (Administrative Procedure Act) and chapter
				  182-526 WAC (HCA administrative hearing rules).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-549 - Rural health clinics › Section 182-549-1650 - Rural health clinics-Appeals related to rate setting

Current through Register Vol. 24-14, July 15, 2024
(1) An RHC provider
				has a right to an administrative appeal of agency action related to rate
				setting under this chapter based on the rules in this section.
(a) The rules in WAC
				182-502-0220
				do not apply to appeals of agency action related to rate setting under this
				chapter.
(b) Appeals related to
				rate setting under this section are not governed by the Administrative
				Procedure Act, chapter 34.05 RCW.
(c) Any rate change that the agency grants
				that is the result of fraudulent practices on the part of the RHC, including as
				described under
				RCW
				74.09.210, is exempt from the appeal
				provisions in this chapter.
(d) An
				RHC who fails to submit requested information as outlined in this chapter will
				be determined to have abandoned their appeal.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-1000 - Applicability

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency pays for hospital services provided to
				  eligible clients when:
(1) The
				eligible client is a patient in an acute care hospital and the hospital meets
				the definition of hospital or psychiatric hospital in
				RCW
				70.41.020, chapter 182-500 or WAC
				182-550-1050;
(2) The services are medically necessary as
				defined under WAC
				182-500-0070; and
(3) The conditions, exceptions and
				limitations in this chapter are met.
11-14-075, recodified as §
											182-550-1000, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-11-129, §
					 388-550-1000, filed 5/22/07, 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, § 388-550-1000, 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 182-550-1100 - Hospital care-General

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency:
(a) Pays for an eligible Washington
				apple health client's admission to a hospital only when the client's attending
				physician orders admission and when the admission and treatment provided:
(i) Are covered under WAC
				182-501-0050,
				182-501-0060 and
				182-501-0065;
(ii) Are medically necessary as defined in
				WAC 182-500-0070;
(iii) Are determined according to WAC
				182-501-0165 when prior
				authorization is required;
(iv) Are
				authorized when required under this chapter; and
(v) Meet applicable state and federal
				requirements.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-1200 - Restrictions on hospital coverage

Current through Register Vol. 24-14, July 15, 2024
A hospital covered service provided to a person eligible
				  under a Washington apple health (WAH) program that is paid by the agency's
				  fee-for-services payment system must be within the scope of the person's WAH
				  program. Coverage restriction includes, but is not limited to the
				  following:
(1) Persons enrolled with
				the agency's managed care organization (MCO) plans are subject to the
				respective plan's policies and procedures for coverage of hospital
				services;
(2) Persons covered by
				primary care case management are subject to the persons' primary care
				physicians' approval for hospital services;
(3) For emergency care exemptions for persons
				described in subsections (1) and (2) of this section, see WAC
				182-538-100;
(4) Health care services provided by a
				hospital located out-of-state are:
(a) Not
				covered for persons eligible under the medical care services (MCS) program.
				However, persons eligible for MCS are covered for that program's scope of care
				in bordering city and critical border hospitals.
(b) Covered for:
(i) Emergency care for eligible medicaid and
				CHIP persons without prior authorization, based on the medical necessity and
				utilization review standards and limits established by the agency.
(ii) Nonemergency out-of-state care for
				medicaid and CHIP persons when prior authorized by the agency based on the
				medical necessity and utilization review standards and limits.
(iii) Hospitals in bordering cities and
				critical border hospitals, based on the same client eligibility criteria and
				authorization policies as for instate hospitals. See WAC
				182-501-0175 for a list of
				bordering cities.
(c)
				Covered for out-of-state voluntary inpatient psychiatric hospital services for
				eligible medicaid and CHIP clients based on authorization by a division of
				behavioral health and recovery (DBHR) designee.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-1300 - Revenue code categories and subcategories

Current through Register Vol. 24-14, July 15, 2024
(1) Revenue code categories and subcategories
				listed in this chapter are published in the UB-92 or UB-04 National Uniform
				Billing Data Element Specifications Manual.
(2) The medicaid agency requires a hospital
				provider to report and bill all hospital services provided to Washington apple
				health clients using the appropriate revenue codes published in the manual
				referenced in subsection (1) of this section.
11-14-075, recodified as §
											182-550-1300, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-14-018, §
					 388-550-1300, filed 6/22/07, effective 8/1/07. Statutory Authority:
					 RCW
					 74.04.050,
					 74.04.057,
					 74.08.090, and
					 Public Law
					 104-191. 03-19-044, § 388-550-1300, filed
					 9/10/03, effective 10/11/03. 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, § 388-550-1300, 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 182-550-1600 - Specific items/services not covered

Current through Register Vol. 24-14, July 15, 2024
The medicaid agency does not pay for an inpatient or
				  outpatient hospital service, treatment, equipment, drug, or supply that is not
				  listed or referred to as a covered service in this chapter. The following list
				  of noncovered items and services is not intended to be all-inclusive.
				  Non-covered items and services include, but are not limited to:
(1) Personal care items such as, but not
				limited to, slippers, toothbrush, comb, hair dryer, and make-up;
(2) Telephone/telegraph services or
				television/radio rentals;
(3)
				Medical photographic or audio/videotape records;
(4) Crisis counseling;
(5) Psychiatric day care;
(6) Ancillary services, such as respiratory
				and physical therapy, performed by regular nursing staff assigned to the floor
				or unit;
(7) Standby personnel and
				travel time;
(8) Routine hospital
				medical supplies and equipment such as bed scales;
(9) Handling fees and portable X-ray
				charges;
(10) Room and equipment
				charges ("rental charges") for use periods concurrent with another room or
				similar equipment for the same client;
(11) Cafeteria charges; and
(12) Services and supplies provided to
				nonpatients, such as meals and "father packs."
11-14-075, recodified as §
											182-550-1600, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-14-018, §
					 388-550-1600, filed 6/22/07, 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, § 388-550-1600, 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 182-550-1650 - Adverse events, hospital-acquired conditions, and present on admission indicators

Current through Register Vol. 24-14, July 15, 2024
(1) The rules in
				this section apply to:
(a) Inpatient hospital
				claims with dates of admission on and after January 1, 2010;
(b) Payment or denial of payment for any
				inpatient hospital claims identified in (a) of this subsection, including
				medicaid supplemental or enhanced payments and medicaid disproportionate share
				hospital (DSH) payments or denial of payment;
(c) Adverse events, hospital-acquired
				conditions (HACs), and present on admission (POA) indicators (defined in
				subsection (2) of this section);
(d) Hospital requirements to report adverse
				events and HACs to the department (see subsection (4)(a) of this
				section);
(e) Hospital requests for
				retrospective utilization reviews and the related requirements to provide root
				cause analysis of events to the department (see subsection (4)(d) through (f)
				of this section); and
(f) Hospital
				requirements to use POA indicator codes on claims (see subsection (5)(a) of
				this section).
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-1700 - Authorization and utilization review (UR) of inpatient and outpatient hospital services

Current through Register Vol. 24-14, July 15, 2024
(1) This section
				applies to the agency's authorization and utilization review (UR) of inpatient
				and outpatient hospital services provided to Washington apple health medic-aid)
				clients receiving services through the fee-for-service program. For clients
				enrolled in an agency-contracted managed care organization (MCO), see chapters
				182-538 and 182-538D WAC. See chapter 182-546 WAC for transportation
				services.
(2) All hospital services
				paid for by the agency are subject to UR for medical necessity, appropriate
				level of care, and program compliance.
(3) Authorization for inpatient and
				outpatient hospital services is valid only if a client is eligible for covered
				services on the date of service. Authorization does not guarantee
				payment.
(4) The agency will deny,
				recover, or adjust hospital payments if the agency or its designee determines,
				as a result of UR, that a hospital service does not meet the requirements in
				federal regulations and WAC.
(5)
				The agency may perform one or more types of UR described in subsection (6) of
				this section.
(6) The agency's UR:
(a) Is a concurrent, prospective, and/or
				retrospective (including postpay and prepay) formal evaluation of a client's
				documented medical care to assure that the services provided are proper and
				necessary and of good quality. The review considers the appropriateness of the
				place of care, level of care, and the duration, frequency or quantity of
				services provided in relation to the conditions(s) being treated; and
(b) Includes one or more of the following:
(i) "Concurrent utilization review"-An
				evaluation performed by the agency or its designee during a client's course of
				care. A continued stay review performed during the client's hospitalization is
				a form of concurrent UR;
(ii)
				"Prospective utilization review"-An evaluation performed by the agency or its
				designee prior to the provision of health care services. Preadmission
				authorization is a form of prospective UR; and
(iii) "Retrospective utilization review"-An
				evaluation performed by the agency or its designee following the provision of
				health care services that includes both a post-payment retrospective UR
				(performed after health care services are provided and paid), and a prepayment
				retrospective UR (performed after health care services are provided but prior
				to payment). Retrospective UR is routinely performed as an audit
				function.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-1800 - Hospital specialty services not requiring prior authorization

Current through Register Vol. 24-14, July 15, 2024
The department pays for certain specialty services without
				  requiring prior authorization when such services are provided consistent with
				  department medical necessity and utilization review standards. These services
				  include, but are not limited to, the following:
(1) All transplant procedures specified in
				WAC 388-550-1900(2) under the conditions established in WAC
				388-550-1900;
(2) Chronic pain
				management services, including outpatient evaluation and inpatient treatment,
				as described under WAC 388-550-2400;
(3) Polysomnograms and multiple sleep latency
				tests for clients one year of age and older (allowed only in outpatient
				hospital settings), as described under WAC 388-550-6350;
(4) Diabetes education (allowed only in
				outpatient hospital setting), as described under WAC 388-550-6400;
				and
(5) Weight loss program
				(allowed only in outpatient hospital setting), as described under WAC
				388-550-6450.
11-14-075, recodified as §
											182-550-1800, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.500. 07-14-018, §
					 388-550-1800, filed 6/22/07, 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, § 388-550-1800, 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 182-550-1900 - Transplant coverage

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency pays for medically necessary transplant procedures only for eligible
				Washington apple health clients who are not otherwise subject to a managed care
				organization (MCO) plan. Clients eligible under the alien emergency medical
				(AEM) program are not eligible for transplant coverage.
(2) The agency covers the following
				transplant procedures when the transplant procedures are performed in a
				hospital designated by the agency as a "center of excellence" for transplant
				procedures and meet that hospital's criteria for establishing appropriateness
				and the medical necessity of the procedures:
(a) Solid organs involving the heart, kidney,
				liver, lung, heart-lung, pancreas, kidney-pancreas, and small bowel;
(b) Bone marrow and peripheral stem cell
				(PSC);
(c) Skin grafts;
				and
(d) Corneal
				transplants.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2100 - Requirements - Transplant hospitals

Current through Register Vol. 24-14, July 15, 2024
This section applies to requirements for hospitals that
				  perform the medicaid agency-approved transplants described in WAC
				  182-550-1900(2).
(1) The agency requires instate transplant
				hospitals to meet the following requirements to be paid for transplant services
				provided to Washington apple health clients. A hospital must have:
(a) An approved certificate of need (CON)
				from the state department of health (DOH) for the type of transplant procedure
				to be performed, except that the agency does not require CON approval for a
				hospital that provides peripheral stem cell (PSC), skin graft or corneal
				transplant services;
(b) Approval
				from the United Network of Organ Sharing (UNOS) to perform transplants, except
				that the agency does not require UNOS approval for a hospital that provides
				PSC, skin graft, or corneal transplant services; and
(c) Been approved by the agency as a center
				of excellence transplant center for the specific organ or procedure the
				hospital proposes to perform.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2200 - Transplant requirements-COE

Current through Register Vol. 24-14, July 15, 2024
(1) The
				medicaid agency measures the effectiveness of transplant centers of excellence
				(COE) using the performance criteria in this section. Unless otherwise waived
				by the agency, the agency applies these criteria to a hospital during both
				initial and periodic evaluations for designation as a transplant COE. The COE
				performance criteria must include, but not be limited to:
(a) Meeting annual volume requirements for
				the specific transplant procedures for which approved;
(b) Patient survival rates; and
(c) Relative cost per case.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2301 - Hospital and medical criteria requirements for bariatric surgery

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency pays a hospital for bariatric surgery and bariatric surgery-related
				services only when the surgery is provided in an inpatient hospital setting and
				only when:
(a) The client:
(i) Qualifies for bariatric surgery by
				successfully completing all requirements under WAC
				182-531-1600; and
(ii) Continues to meet the criteria to
				qualify for bariatric surgery under WAC
				182-531-1600 up to the actual
				surgery date.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2400 - Inpatient chronic pain management services

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid agency pays a hospital that
				is specifically approved by the agency to provide inpatient chronic pain
				management services, an all-inclusive per diem facility fee. The agency pays
				professional fees for chronic pain management services to performing providers
				under the agency's fee schedule.
(2) A client qualifies for inpatient chronic
				pain management services when all the following apply:
(a) The client has had pain for at least
				three months and has not improved with conservative treatment, including tests
				and therapies;
(b) At least six
				months have passed since a previous surgical procedure was done concerning the
				pain problem; and
(c) A client with
				active substance abuse must have completed a withdrawal management program, if
				appropriate, and must be free from drugs and/or alcohol for at least six
				months.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2431 - Hospice services-Inpatient payments

Current through Register Vol. 24-14, July 15, 2024
See chapter 182-551 WAC Alternatives to hospital services,
				  subchapter I-Hospice services.
11-14-075, recodified as §
											182-550-2431, filed 6/30/11,
					 effective 7/1/11. 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,
					 § 388-550-2431, filed 2/26/99, effective
					 3/29/99.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2500 - Inpatient hospice services

Current through Register Vol. 24-14, July 15, 2024
(1) The
				medicaid agency pays hospice agencies participating in the Washington apple
				health program for general inpatient and inpatient respite services provided to
				clients in hospice care, when:
(a) The
				hospice agency coordinates the provision of the inpatient services;
				and
(b) The services are related to
				the medical condition for which the client sought hospice care.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2501 - Acute physical medicine and rehabilitation (acute PM&R) program-General

Current through Register Vol. 24-14, July 15, 2024
Acute physical medicine and rehabilitation (acute PM&R)
				  is a twenty-four-hour inpatient comprehensive program of integrated medical and
				  rehabilitative services provided during the acute phase of a client's
				  rehabilitation. The medicaid agency requires prior authorization for acute
				  PM&R services. (See WAC
				  182-550-2561 for prior
				  authorization requirements.)
(1) An
				interdisciplinary team coordinates individualized acute PM&R services at an
				agency-approved rehabilitation hospital to achieve the following for a client:
(a) Improved health and welfare;
				and
(b) Maximum physical, social,
				psychological, and educational or vocational potential.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2511

Current through Register Vol. 24-14, July 15, 2024
11-14-075, recodified as §
											182-550-2511, filed 6/30/11,
					 effective 7/1/11. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.09.500. 07-12-039, §
					 388-550-2511, filed 5/30/07, effective 8/1/07. Statutory Authority:
					 RCW
					 74.08.090,
					 74.09.520 and
					 42 C.F.R.
					 482.56. 03-06-047, § 388-550-2511, filed
					 2/28/03, effective 3/31/03. Statutory Authority:
					 RCW
					 74.08.090 and
					 74.09.520. 99-17-111, §
					 388-550-2511, filed 8/18/99, effective
					 9/18/99.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2521 - Client eligibility requirements for acute PM&R services

Current through Register Vol. 24-14, July 15, 2024
(1) Only a client
				who is eligible for one of the Washington apple health programs may receive
				acute PM&R services, subject to the restrictions and limitations in this
				section and WAC
				182-550-2501,
				182-550-2511,
				182-550-2531,
				182-550-2541,
				182-550-2551,
				182-550-2561,
				182-550-3381, and other rules:
(a) Categorically needy program
				(CNP);
(b) Children's health
				insurance program (CHIP);
(c)
				Medically needy program (LCP-MNP);
(d) Alien emergency medical
				(AEM)(CNP);
(e) Alien emergency
				medical (AEM)(LCP-MNP);
(f) Medical
				care services.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2531 - Requirements for becoming an acute PM&R provider

Current through Register Vol. 24-14, July 15, 2024
(1) Before August 1, 2007, only an in-state
				or bordering city hospital may apply to become a medicaid agency-approved acute
				PM&R hospital. After July 31, 2007, an in-state, bordering city or critical
				border hospital may apply to become an agency-approved acute PM&R hospital.
				To apply, the agency requires the hospital provider to submit a letter of
				request to:
Acute PM&R Program Manager
Clinical Quality and Care Transformation (CQCT)
Medical and Dental Services
P. O. Box 45506
Olympia, WA 98504-5506
(2) A hospital that applies to become an
				agency-approved acute PM&R facility must provide the agency with
				documentation that confirms the facility is all the following:
(a) A medicare-certified hospital;
(b) Accredited by the joint commission on
				accreditation of health care organizations (JCAHO);
(c) Licensed by the department of health
				(DOH) as an acute care hospital as defined under WAC
				246-310-010;
(d) Commission on accreditation of
				rehabilitation facilities (CARF) accredited as a comprehensive integrated
				inpatient rehabilitation program or as a pediatric family centered
				rehabilitation program, unless subsection (3) of this section
				applies;
(e) For dates of admission
				before July 1, 2007, contracted under the agency's selective contracting
				program, if in a selective contracting area, unless exempted from the
				requirements by the agency; and
(f)
				Operating per the standards set by DOH (excluding the certified rehabilitation
				registered nurse (CRRN) requirement) in either:
(i) WAC
				246-976-800 Level I trauma
				rehabilitation designation; or
(ii)
				WAC 246-976-800 Level II trauma
				rehabilitation designation.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2541 - Quality of care-Agency-approved acute PM&R hospital

Current through Register Vol. 24-14, July 15, 2024
(1) To ensure quality of care, the medicaid
				agency may conduct reviews (e.g., post-pay, on-site) of any agency-approved
				acute PM&R hospital.
(2) A
				provider of acute PM&R services must act on any report of substandard care
				or violation of the hospital's medical staff bylaws and CARF standards. The
				provider must have and follow written procedures that:
(a) Provide a resolution to either a
				complaint or grievance or both; and
(b) Comply with applicable CARF standards for
				adults or pediatrics as appropriate.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2551 - When the medicaid agency authorizes acute PM&R services

Current through Register Vol. 24-14, July 15, 2024
(1) Acute PM&R
				services may be authorized when all of the following are met:
(a) The client has all of the following:
(i) Extensive or complex medical
				needs;
(ii) Nursing needs;
				and
(iii) Therapy needs.
Washington Administrative Code › Title 182 - Health Care Authority › WASHINGTON APPLE HEALTH › Chapter 182-550 - Hospital services › Section 182-550-2561 - The agency's prior authorization requirements for acute PM&R services

Current through Register Vol. 24-14, July 15, 2024
(1) The medicaid
				agency requires prior authorization for acute PM&R services. The acute
				PM&R provider of services must obtain prior authorization:
(a) Before admitting a client to the
				rehabilitation unit; and
(b) For an
				extension of stay before the client's current authorized period of stay
				expires.