Washington Administrative Code

(1) Patient review and coordination (PRC) is a health and safety program that coordinates care and ensures clients enrolled in PRC use services appropriately and in accordance with agency rules and policies.(a) PRC applies to medical assistance fee-for-service (FFS) clients and m…

A client or the client's provider may request that the medicaid agency or its designee pay for a noncovered health care service. This is called an exception to rule (ETR). The request for ETR must be made before the service is rendered.(1) The agency's medical director or designe…

(1) The medicaid agency requires providers to obtain authorization for certain health care services under this section, chapters 182-501 and 182-502 WAC, other applicable agency rules, current published agency billing instructions, and numbered memoranda. For the purposes of this…

(1) This section applies to fee-for-service (FFS) requests for medical or dental services and medical equipment that:(a) Are identified as covered services or early and periodic screening, diagnosis, and treatment services; and(b) Require prior authorization by the medicaid agenc…

This section addresses requests for limitation extensions regarding scope, amount, duration, and frequency of a covered health care service. For the purposes of this section, health care services includes treatment, equipment, related supplies, and drugs. The medicaid agency does…

(1) An eligible Washington state resident may receive medical care in a recognized out-of-state bordering city on the same basis as in-state care.(2) The only recognized bordering cities are:(a) Coeur d'Alene, Moscow, Sandpoint, Priest River, and Lewiston, Idaho; and(b) Portland,…

WAC 182-501-0180 through 182-501-0184 describe the health care services available to a Washington apple health client on a fee-for-service basis or to a client enrolled in a managed care organization (MCO) (defined in WAC 182-538-050).(1) Subject to the requirements, exceptions, …

(1) This rule applies to nonemergency treatment situations occurring in another state or U.S. territory. Applicable situations include, but are not limited to:(a) Health care services the medicaid agency has prior authorized for a client; and(b) Health care services obtained by t…

For the purposes of this section, the term "health care services" does not include the diagnosis and treatment for alcohol, substance abuse, and mental health services.(1) The provisions of WAC 182-501-0182 apply to this section.(2) The medicaid agency does not pay for health car…

(1) The medicaid agency requires a provider to seek timely reimbursement from a responsible third party when a client has available third-party resources, except as described under subsections (2) and (3) of this section. Responsible third parties include health insurers and othe…

(1) The medicaid agency provides case management services to Washington apple health recipients:(a) By contract with providers of case management services.(b) Limited to target groups of clients as determined by the contract.(c) Limited to services as determined by the contract.(…

(1) Wraparound with intensive services (WISe) is a service delivery model that provides comprehensive behavioral health covered services and support to:(a) Clients age 20 or younger with complex behavioral health needs who are eligible for coverage under WAC 182-505-0210; and(b) …

(1) Purpose and scope.(a) This section identifies the requirements and limitations for coverage, authorization, and payment of health care services provided through telemedicine or store and forward technologies as defined in subsection (2) of this section.(b) This section applie…

The following health care professionals, health care entities, suppliers or contractors of service may request enrollment with the Washington state health care authority (medicaid agency) to provide covered health care services to eligible clients. For the purposes of this chapte…

The medicaid agency does not enroll licensed or unlicensed health care practitioners not specifically listed in WAC 182-502-0002, including, but not limited to:(1) Acupuncturists;(2) Sanipractors;(3) Homeopaths;(4) Herbalists;(5) Massage therapists;(6) Christian science practitio…

(1) The agency only enrolls a health care professional, health care entity, supplier, or contractor of service through approval of an application for:(a) A core provider agreement (CPA);(b) A nonbilling provider agreement; or(c) Adding a servicing provider under either a CPA or a…

(1) Nothing in this chapter obligates the medicaid agency to enroll any eligible health care professional, health care entity, supplier, or contractor of service who requests enrollment.(2) To enroll as a provider (as defined in WAC 182-500-0085) with the agency, a health care pr…

(1) The medicaid agency does not enroll a health care professional, health care entity, supplier, or contractor of service for reasons which include, but are not limited to, the following:(a) The agency determines that:(i) There is a quality of care issue with significant risk fa…

(1) The medicaid agency may consider enrolling a health care professional, health care entity, supplier or contractor of service for reasons which include, but are not limited to, the following:(a) The agency determines that:(i) There is not a quality of care issue with significa…

(1) To continue to provide services for eligible clients and be paid for those services, a provider must:(a) Provide all services without discriminating on the grounds of race, creed, color, age, sex, sexual orientation, religion, national origin, marital status, the presence of …

(1) The medicaid agency (agency) requires any entity (including providers) that makes or receives medical assistance payments from the agency or the agency designee of at least $5,000,000 annually under the state plan to meet the requirements of Section 1902 (a)(68) of the Social…

(1) A provider must notify the medicaid agency in writing within seven calendar days of ownership or control changes of any kind. An entity is considered to have an ownership or control interest in another entity if it has direct or indirect ownership of five percent or more, or …

This section applies to providers, as defined under WAC 182-500-0085 and under WAC 182-538-050. Providers must:(1) Maintain documentation in the client's medical or health care records to verify the level, type, and extent of services provided to each client to fully justify the …

(1) This section establishes the agency's payment policy for services provided to medicaid clients on a fee-for-service basis or to a client enrolled in a managed care organization (defined in WAC 182-538-050) by health care professionals and inpatient hospitals that result in pr…

The purpose of this section is to establish the medicaid electronic health records (EHR) incentive program under the American Recovery and Reinvestment Act of 2009 (ARRA). The medicaid EHR incentive program promotes the adoption and meaningful use of certified EHR technology by o…

(1) The medicaid agency may immediately terminate a provider's enrollment for any one or more of the following reasons, each of which constitutes cause:(a) Provider exhibits significant risk factors that endanger client health or safety. These factors include, but are not limited…

(1) Either the medicaid agency or the provider may terminate the provider's enrollment with the agency for convenience with 28 calendar days written notice in a manner which provides proof of receipt or proof of valid attempt to deliver the notice.(2) Termination of enrollment fo…

The process described in this section applies only when agency rules allow a provider to dispute an agency decision under this section.(1) In order for the agency to review a decision previously made by the agency, a provider must submit the request to review the decision:(a) Wit…

A provider who is terminated solely under WAC 182-502-0030(3) is eligible for immediate reapplication with the medicaid agency if the provider is not a full or partial owner of a terminated group practice.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-21-067, § 182-502…

(1) The medicaid agency pays for health care services furnished to an eligible client when the claim satisfies agency rules including all the following:(a) The service is within the scope of care of the client's Washington apple health program;(b) The service is medically necessa…

(1) The following people are eligible for benefits under this section:(a) Dual-eligible clients enrolled in categorically needy Washington apple health programs;(b) Dual-eligible clients enrolled in medically needy Washington apple health programs; or(c) Clients enrolled in the q…

(1) The medicaid agency pays for health care services provided outside the state of Washington only when the service meets the provisions described in WAC 182-501-0180, 182-501-0182, 182-501-0184, and specific program WAC.(2) With the exception of hospital services and nursing fa…

(1) Providers who are enrolled as contractors with the medicaid agency's medical care programs may be assessed interest on excess benefits or other inappropriate payments. Nursing home providers are governed by WAC 388-96-310 and are not subject to this section.(2) The agency ass…

Providers must bill the medicaid agency for covered services provided to eligible clients as follows:(1) The agency requires providers to submit initial claims and adjust prior claims in a timely manner. The agency has three timeliness standards:(a) For initial claims, see subsec…

(1) The purpose of this section is to specify the limited circumstances in which:(a) Fee-for-service or managed care clients can choose to self-pay for medical assistance services; and(b) Providers (as defined in WAC 182-500-0085) have the authority to bill fee-for-service or man…

(1) At the request of the medicaid agency, all providers enrolled with agency programs must submit full reports, as specified by the agency, of goods and services furnished to eligible Washington apple health clients. The agency furnishes the provider with a standardized format t…

(1) Any enrolled contractor or provider of medical services has a right to an administrative appeal when the contractor or provider disagrees with the medicaid agency reimbursement rate. The exception to this is nursing facilities governed by WAC 388-96-904.(2) The first level of…

(1) This section applies to provider overpayment disputes with providers who furnish health care services to Washington apple health clients, except those overpayment disputes to which chapter 182-502A WAC applies. For the purposes of this section:(a) "Agency" means the health ca…

(1) Providers of medical services who have a contract, other than a core provider agreement, with a dispute resolution provision must follow the dispute resolution process described in the contract.(2) See WAC 182-502-0220 for disputes involving rates. See chapter 182-502A WAC fo…

(1) This section applies only when agency rules allow review of an agency dispute decision under this section. The director of the health care authority or designee conducts the review.(2) Providers and former providers may request a review of an agency dispute decision. The requ…

(1) Program integrity means a system of reasonable and consistent oversight of the medicaid program.(2) The medicaid agency conducts program integrity activities to detect and prevent potential fraud, waste, and abuse. These activities include identifying improper payments and re…

The definitions in this section and those found in chapter 182-500 WAC apply throughout this chapter.Adverse determination means a finding of an overpayment identified in a program integrity activity.Algorithm means the set of rules applied to claim or encounter data to identify …

The medicaid agency conducts program integrity activities on all Title XIX, Title XXI, and state-only-funded expenditures. See 42 C.F.R. 2.54, 431, 433, 438, 447, 455, 456, 457, 495, and 1001; 45 C.F.R. 92; 42 U.S.C. 1396a; and chapters 41.05, 41.05A, and 74.09 RCW.[Statutory Aut…

The medicaid agency verifies entities' compliance with applicable laws, rules, regulations, and agreements through program integrity activities.(1) Methods. Program integrity activity methods include, but are not limited to:(a) Data mining to identify possible fraud, waste, and a…

(1) The medicaid agency may require an entity to self-audit.(a) The agency gives written notice of the instruction to self-audit.(b) The entity must acknowledge receipt of the notice within thirty calendar days of receiving it.(c) The entity must comply with all terms included in…

(1) To determine an improper payment from a sample, the medicaid agency may extrapolate to the universe from which the sample was drawn:(a) If the audit identifies a sustained high level of payment error involving the provider; or(b) When the agency has documented educational int…

(1) Following the medicaid agency's evaluation of an entity's records including, but not limited to, claims, encounter data, or payments, the agency may do any combination of the following:(a) Deny a claim or claim line.(b) Recover an improperly paid claim.(c) Instruct the entity…

(1) An entity may informally dispute a preliminary finding. The medicaid agency must receive any request for dispute resolution within thirty calendar days of the date the entity received the preliminary finding. The request for dispute resolution must be in writing and include t…

(1) An entity has a right to an administrative hearing (formal appeal), and any resulting appeals process under RCW 41.05A.170 and chapter 182-526 WAC, if the agency assesses an overpayment against the entity.(2) An entity does not have an administrative hearing right for the den…

(1) The medicaid agency annually, compiles and publishes metrics for any contractor that conducts audits on the agency's behalf under RCW 74.09.195 (2)(b).(2) The agency may publish metrics of the program integrity activities it conducts. Metrics include, but are not limited to:(…