Washington Administrative Code

(1) A party must make the request for review of an initial order in writing and file the request with the board of appeals (BOA) at the address given in WAC 182-526-0030 and within the deadlines set forth in WAC 182-526-0580.(2) The request for review should identify the parts of…

(1) The board of appeals (BOA) must receive the written review request of an initial order on or before 5:00 p.m. on the 21st calendar day after the initial order was served, unless an extension of the deadline is granted by the review judge.(2) A party may file the written revie…

(1) A party does not have to respond to the request for review. A response is optional.(2) If a party decides to respond, that party must file the response so that the board of appeals (BOA) receives it on or before the seventh business day after the date the other party's review…

(1) After the response deadline, the record on review is closed unless the review judge finds there is a good reason to keep it open.(2) A review judge is assigned to review the initial order after the record on review is closed. To find out which judge is assigned, call the boar…

(1) In some cases, review judges review initial orders and enter final orders. The review judge has the same decision-making authority as the administrative law judge (ALJ). The review judge considers the entire record and decides the case de novo (anew). In reviewing findings of…

(1) If a party does not agree with the final order and wants it reconsidered, the party may request the review judge to reconsider the decision.(2) The party must make the request in writing and clearly state why the party wants the final order reconsidered. The party must file t…

(1) To request reconsideration of a final order entered by a review judge, the BOA must receive a written reconsideration request on or before the tenth calendar day after the final order was served.(2) The review judge may extend its deadline for filing a request for reconsidera…

(1) A party does not have to respond to a request for reconsideration of a final order. A response is optional.(2) If a party responds, that party must file a response with the board of appeals (BOA) by or before the seventh business day after the date the review judge mailed the…

(1) After the review judge receives a reconsideration request, the review judge has twenty calendar days to enter and serve a reconsideration decision unless the review judge serves notice allowing more time.(2) After the BOA receives a reconsideration request, the review judge m…

(1) Judicial review is the process of appealing a final order to a court.(2) The party that requested the hearing may appeal a final order by filing a written petition for judicial review that meets the requirements of RCW 34.05.546. HCA may not request judicial review.(3) The pa…

A party must file a petition for judicial review with the superior court within thirty calendar days after the final order is served to the parties.[Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0645, filed 12/19…

Generally, a party may file a petition for judicial review only after it has completed the administrative hearing process. See RCW 34.05.534.[Statutory Authority: 2011 1st sp.s. c 15 § 53, chapters 74.09, 34.05 RCW, and 10-08 WAC. WSR 13-02-007, § 182-526-0647, filed 12/19/12, ef…

(1) The party requesting judicial review must:(a) File a petition for judicial review with the court;(b) File and serve the petition for judicial review of a final order within 30 days after the date it was mailed to the parties; and(c) Serve copies of the petition on the health …

The following definitions apply to this chapter:"Contract health service delivery area (CHSDA)" means the geographic area within which contract health services will be made available by the Indian health service to members of an identified Indian community who reside in the area …

For the purposes of this section, the term "agency" includes the agency's designee.(1) When the agency may file.(a) The agency may file a lien against the property of a Washington apple health client during the client's lifetime if:(i) The client resides in a skilled nursing faci…

For the purposes of this section, the term "agency" includes the agency's designee.(1) When the agency may file. After a Washington apple health client has died, the medicaid agency may file liens to recover the cost of services subject to recovery that were correctly paid on the…

For the purposes of this section, the term "agency" includes the agency's designee.(1) Liability for medicaid services.(a) Beginning July 26, 1987, a client's estate is liable for medicaid services subject to recovery that were provided on or after the client's 65th birthday.(b) …

For the purposes of this section, the term "agency" includes the agency's designee.The agency's payment for the following services is subject to recovery:(1) State-only funded services, except:(a) Adult protective services;(b) Offender reentry community safety program services;(c…

For the purposes of this section, the term "agency" includes the agency's designee.(1) Before July 25, 1993. For services received before July 25, 1993, that are subject to recovery, the agency may exempt:(a) The first fifty thousand dollars of the estate's value at the time of t…

For the purposes of this section, the term "agency" includes the agency's designee.(1) If an undue hardship exists at the time of the client's death, an heir may ask the agency to delay recovery.(a) Undue hardship exists only when:(i) The property subject to recovery is the sole …

For the purposes of this section, the term "agency" includes the agency's designee.(1) An administrative hearing to contest action under this chapter determines only:(a) In the case of a lien filed during the client's lifetime under WAC 182-527-2734:(i) Whether the client can rea…

(1) The purpose of the outpatient drug program is to reimburse providers for outpatient drugs, vitamins, minerals, devices, and drug-related supplies according to medicaid agency rules and subject to the limitations and requirements in this chapter.(2) The agency reimburses for o…

In addition to the definitions and abbreviations found in chapter 182-500 WAC, Medical definitions, the following definitions apply to this chapter."340B program" - The federal program that requires drug manufacturers participating in the medicaid drug rebate program (MDRP) to pr…

(1) The medicaid agency requires providers to use tamper-resistant prescription pads or paper for written outpatient prescriptions, including over-the-counter drugs, for Washington apple health clients.(2) This requirement applies to all outpatient prescription drugs, including:(…

This section identifies the steps prescribers must take before prescribing a controlled substance and the steps pharmacists must take when dispensing a controlled substance from an outpatient pharmacy to check an apple health client's prescription drug history in the prescription…

(1) The medicaid agency covers:(a) Outpatient drugs, including over-the-counter (OTC) drugs, as defined in WAC 182-530-1050, subject to the limitations and requirements in this chapter, when:(i) The drug is approved by the Food and Drug Administration (FDA);(ii) The drug is for a…

(1) The medicaid agency does not cover:(a) A drug that is:(i) Not approved by the Food and Drug Administration (FDA); or(ii) Prescribed for a nonmedically accepted indication, including diagnosis, dose, or dosage schedule that is not evidenced-based.(b) A drug prescribed:(i) For …

Covered drugs, devices, or drug-related supplies require authorization for reimbursement when:(1) The medicaid agency's pharmacists or medical consultants:(a) Have determined that authorization for the drug, device, or drug-related supply is required, as described in WAC 182-530-…

(1) The medicaid 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 avai…

(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 publishe…

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 m…

(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 fo…

(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-base…

(1) The medicaid agency may require preferred generic drugs on the Washington preferred drug list (Washington PDL) be used before any brand name or nonpreferred generic drugs for a client's first course of treatment within that therapeutic class of drugs, according to RCW 69.41.1…

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 (Washin…

(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; …

(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 identif…

(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…

Clients may elect to receive pharmacy services through any mail-order or specialty pharmacy enrolled with the agency. (1) Mail-order pharmacies or specialty pharmacies licensed to do business in Washington state under RCW 18.64.360 may enroll with the agency in the same manner as…

(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…

(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; o…

(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…

(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 …

(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 agen…

(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 au…

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 curtail…

(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 t…

(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 …

(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 list…

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…