Washington Administrative Code

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) Medi…

(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…

(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 foll…

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…

(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 d…

(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…

The following definitions and abbreviations and those found in chapter 182-500 WAC, apply to this chapter."Actual acquisition cost" - See WAC 182-530-1050."Acute care" - Care provided for clients who are not medically stable. These clients require frequent monitoring by a health …

(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 progr…

(1) The medicaid agency evaluates a request for noncovered services in this chapter under WAC 182-501-0160. In addition to noncovered services found in WAC 182-501-0070, except as provided in subsection (2) of this section, the agency does not cover:(a) Acupuncture, massage, or m…

(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 establis…

(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, o…

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 qualified anesthesiologist provider, which includes:(a) Anesthesiologists as defined in RCW 18…

(1) The medicaid agency reimburses anesthesia services on the basis of base anesthesia units (BAU) plus time.(2) The agency 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…

(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 cochle…

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 CH…

(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 …

(1) The medicaid agency pays physicians or qualified health care professionals (QHCPs) for critical care physician-related services to critically ill or injured clients as follows:(a) More than one physician or QHCP if the services provided involve different specialties; or(b) On…

(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 depart…

(1) When the medicaid agency determines a proposed service is experimental or investigational, the agency follows the procedures in this section.(2) The determination of whether to authorize an experimental or investigational service is subject to a medical necessity review under…

The department covers one pre- and one post-HIV/AIDS counseling/testing session per client each time the client is tested for HIV/AIDS.[WSR 11-14-075, recodified as § 182-531-0600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-531-0600,…

The medicaid agency covers the following services without prior authorization when provided in agency-approved centers of excellence. The agency issues periodic publications listing centers of excellence. These services include sleep studies including, but not limited to, polysom…

(l) The department covers inpatient chronic pain management services only when the services are obtained through a department-approved chronic pain facility.(2) A client qualifies for inpatient chronic pain management services when all of the following apply:(a) The client has ha…

(1) The department separately reimburses the attending provider for inpatient hospital professional services rendered by the attending provider during the surgical follow-up period only if the services are performed for an emergency condition or a diagnosis that is unrelated to t…

(1) The medicaid agency pays providers for laboratory services only when:(a) The provider is certified according to Title XVII of the Social Security Act (medicare), if required; and(b) The provider has a clinical laboratory improvement amendment (CLIA) certificate and identifica…

(1) The agency pays for clinical diagnostic laboratory procedures based on the medicare clinical laboratory fee schedule (CLFS). The agency obtains information used to update fee schedule regulations from the CMS CLFS website.(2) The agency updates budget-neutral fees each year b…

(1) The medicaid agency reimburses a provider for one neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU) service per client, per day.(2) The agency pays for NICU and PICU physician-related services when the billing physician or other qualified health care…

(l) The medicaid agency pays eligible providers for the following:(a) Two calls per month for routine medical conditions for a client residing in a nursing facility; and(b) One call per noninstitutionalized client, per day, for an individual physician, except for valid call-backs…

Refer to chapter 182-544 WAC for vision-related hardware coverage.(1) The medicaid agency covers eye examinations, refraction and fitting services. The agency pays for these services without prior authorization as follows:(a) Once every twenty-four months for asymptomatic clients…

(1) The medicaid agency pays for manipulative therapy only when:(a) Provided by an osteopathic physician licensed under chapter 18.57 RCW or naturopathic physicians licensed under chapter 18.36A RCW; and(b) Billed using the appropriate CPT codes that involve the number of body re…

(1) The medicaid agency covers medical services provided to eligible clients who are temporarily located outside the state, subject to the provisions of this chapter and WAC 182-501-0180.(2) Out-of-state border areas as described under WAC 182-501-0175 are not subject to out-of-s…

(1) The medicaid agency covers care plan oversight services only when:(a) The billing physician or other qualified health care professional (QHCP) follows standard current procedural terminology (CPT) coding guidelines;(b) The client is served by a home health agency, a nursing f…

(1) Refer to the medicaid agency's published physician-related services/health care professional services billing guide for a list of:(a) Supplies that are a routine part of office or other outpatient procedures and that cannot be billed separately; and(b) Supplies that can be bi…

(1) This section addresses care of the lower extremities (foot and ankle) referred to as foot care and applies to clients 21 years of age and older.(2) The department covers the foot care services listed in this section when those services are provided by any of the following hea…

(1) The medicaid agency pays for prolonged services based on established medicare guidelines. The services provided may or may not be continuous. The services provided must meet both of the following:(a) Consist of face-to-face contact between the physician or qualified health ca…

(1) The mental health services covered in this section are different from the mental health services covered under community mental health and involuntary treatment programs in chapter 182-538D WAC.(2) Inpatient and outpatient mental health services not covered under chapter 182-…

(1) The medicaid agency reimburses radiology services subject to the limitations in this section and under WAC 182-531-0300.(2) The agency does not make separate payments for contrast material. The exception is low osmolar contrast media (LOCM) used in intrathecal, intravenous, a…

(1) Purpose. For the purposes of this section, sleep studies include polysomnography (PSG), unattended home sleep test (HST), and multiple sleep latency testing (MSLT). The medicaid agency covers attended, full-channel, PSG, MSLT, and unattended HSTs when:(a) Ordered by the clien…

(1) For purposes of this section, sterilization is any medical procedure, treatment, or operation for the purpose of rendering a client permanently incapable of reproducing.Hysterectomy results in sterilization and is not covered by the medicaid agency solely for that purpose. (S…

(1) The agency covers medically necessary bariatric surgery for eligible clients.(2) Bariatric surgery must be performed in a hospital with a bariatric surgery program, and the hospital must be:(a) Located in the state of Washington or approved border cities (see WAC 182-501-0175…

A hemophilia treatment center of excellence (COE) uses a comprehensive care model to provide care for persons with bleeding disorders. The comprehensive care model includes specialized prevention, diagnostic, and treatment programs designed to provide family-centered education, s…

(1) The department covers physician services for three-day alcohol detoxification or five-day drug detoxification services for a client eligible for medical care program services in a department-enrolled hospital-based detoxification center.(2) The department covers treatment in …

(1) Overview of treatment program.(a) Medicaid agency coverage. The medicaid agency covers the services listed in (b) of this subsection to treat gender dysphoria (also referred to as gender incongruence) under WAC 182-501-0050 and 182-531-0100. These services include life-changi…

(1) The agency's global surgical reimbursement for all covered surgeries includes all of the following:(a) The operation itself;(b) Postoperative dressing changes, including:(i) Local incision care and removal of operative packs;(ii) Removal of cutaneous sutures, staples, lines, …

(1) The medicaid agency covers alcohol and substance misuse counseling through screening, brief intervention, and referral to treatment (SBIRT) services when delivered by, or under the supervision of, a qualified licensed physician or other qualified licensed health care professi…

(1) The medicaid agency covers tobacco/nicotine cessation counseling when:(a) Delivered by qualified providers through an agency-approved tobacco/nicotine cessation telephone counseling service;(b) The client is pregnant or in the postpartum period as defined in 42 C.F.R. 435.170…

(1) The purpose of treat and refer services is to reduce the number of avoidable emergency room transports, i.e., transports that are nonemergency or nonurgent.(2) Treat and refer services are covered health care services for a client who has accessed 911 or a similar public disp…

The medicaid agency covers transplants when performed in a facility, as defined in WAC 247-04-020, that has a transplant certificate of need (CON) issued by the department of health. See WAC 182-550-1900 for information regarding transplant coverage.[Statutory Authority: RCW 41.0…

See WAC 182-550-2000 for information about medical criteria to receive transplants.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-04-039, § 182-531-1800, filed 1/25/17, effective 2/25/17. WSR 11-14-075, recodified as § 182-531-1800, filed 6/30/11, effective 7/1/11. Sta…

GENERAL PAYMENT METHODOLOGY(l) The medicaid agency bases the payment methodology for most physician-related services on medicare's resource-based relative value scale (RBRVS). The agency obtains information used to update the agency's RBRVS from the centers for medicare and medic…

(1) The medicaid agency pays physicians and related providers for covered services provided to eligible clients on a fee-for-service basis, subject to the exceptions, restrictions, and other limitations listed in this chapter and other published issuances.(2) To receive payment, …