Washington Administrative Code

The following definitions and those found in chapter 182-500 WAC apply to this chapter:"Agency" - See WAC 182-500-0010."Assessment" - For the purposes of this chapter, an assessment is made-up of medically necessary tests given to an individual child by a licensed health care pro…

(1) Contracted school districts may receive medicaid payment for students ages birth through twenty who:(a) Have an active individualized family service plan (IFSP) or individualized education program (IEP); and(b) Who are receiving Title XIX medicaid under a Washington apple hea…

(1) School-based health care services (SBHS) must be delivered by or under the supervision of health care providers who are enrolled with the medicaid agency and who meet state licensure requirements, including active, unrestricted department of health (DOH) licensure. The follow…

Covered school-based health care (SBHS) services include:(1) Evaluations when the child is determined to have a disability, and is in need of early intervention services or special education and health care-related services that result in an individualized education program (IEP)…

Noncovered services include, but are not limited to the following:(1) Applied behavior analysis (ABA);(2) Attending meetings;(3) Charting;(4) Instructional assistant contact;(5) Observation not provided directly after service delivery;(6) Parent consultation;(7) Parent contact;(8…

To receive payment from the medicaid agency for providing school-based health care services (SBHS) to eligible children, a school district must:(1) Enroll as a billing provider in ProviderOne and have a current, signed core provider agreement (CPA) with the agency.(2) Have a curr…

(1) Providers must document all school-based health care services as required in this section and the medicaid agency's school-based health care services (SBHS) billing guide.(2) Documentation to justify billed claims must be maintained for at least six years from the date of ser…

(1) To ensure compliance with program rules, the medicaid agency conducts program integrity activities under chapters 182-502 and 182-502A WAC.(2) School districts must participate in all program integrity activities.(3) School districts are responsible for the accuracy, complian…

(1) This chapter governs services provided under the Washington apple health integrated managed care (IMC) contract.(2) IMC provides physical and behavioral health services to medicaid beneficiaries through managed care.(3) IMC includes enrollees receiving behavioral health servi…

The following definitions and abbreviations and those found in chapter 182-500 WAC apply to this chapter. If conflict exists, this chapter takes precedence."Administrative hearing" means an evidentiary adjudicative proceeding before an administrative law judge or presiding office…

(1) The medicaid agency requires a client to enroll in integrated managed care (IMC) when that client:(a) Is eligible for one of the Washington apple health programs for which enrollment is mandatory;(b) Resides in an area where enrollment is mandatory; and(c) Is not exempt from …

(1) To provide physical or behavioral health services under the apple health IMC contract, a managed care organization (MCO) must:(a) Contract with the agency; and(b) Contract with an agency-contracted behavioral health administrative service organization (BH-ASO) that maintains …

A primary care case management (PCCM) provider or the individual providers in a PCCM group or clinic must:(1) Have a core provider agreement with the medicaid agency;(2) Be a recognized urban Indian health center or tribal clinic;(3) Accept the terms and conditions of the agency'…

(1) The medicaid agency pays apple health managed care organizations (MCOs) monthly capitated premiums that:(a) Have been developed using generally accepted actuarial principles and practices;(b) Are appropriate for the populations to be covered and the services to be furnished u…

(1) The medicaid agency pays PCCM providers a monthly case management fee according to contracted terms and conditions.(2) The agency pays PCCM providers for health care services under the fee-for-service health care delivery system.[Statutory Authority: RCW 41.05.021, 41.05.160,…

Scope of Care.(1) An enrollee in integrated managed care (IMC) is eligible only for the scope of services that are covered based on the apple health program (eligibility program) in which they are enrolled.(a) See the chart in WAC 182-501-0060 for category of covered services tha…

(1) An enrollee is entitled to timely access to covered services that are medically necessary.(2) A primary care case management (PCCM) enrollee is eligible for the scope of services that are covered based on the enrollee's apple health eligibility program. See WAC 182-501-0060 a…

(1) A managed care enrollee may obtain emergency services for emergency medical conditions from any qualified medicaid provider.(a) The managed care organization (MCO) covers emergency services for MCO enrollees.(b) The agency covers emergency services for primary care case manag…

(1) Introduction. This section contains information about the grievance and appeal system and the right to an agency administrative hearing for MCO enrollees. See WAC 182-538-111 for information about PCCM enrollees.(2) Statutory basis and framework.(a) Each MCO must have a griev…

PCCM enrollees follow the same administrative hearing rules and processes as fee-for-service clients under chapter 182-526 WAC.[Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-111, filed 11/27/19, effective 1/1/20. S…

(1) A managed care enrollee has the right to a timely referral for a second opinion upon request when:(a) The enrollee needs more information about treatment recommended by the provider or managed care organization (MCO); or(b) The enrollee believes the MCO is not authorizing med…

The medicaid agency enrolls clients into integrated managed care (IMC) based on the rules in WAC 182-538-060. IMC is mandatory in all regional service areas.(1) Authority to request. The following people may request that the agency approve an exemption or end enrollment in manage…

To assure that managed care enrollees receive quality health care services, the agency requires managed care organizations (MCOs) to comply with quality improvement standards detailed in the agency's managed care contract. MCOs must:(1) Have a clearly defined quality organization…

(1) Unless otherwise stated in this section, all of the provisions of chapter 182-538 WAC apply to apple health foster care (AHFC).(2) The following sections of chapter 182-538 WAC do not apply to AHFC:(a) WAC 182-538-068;(b) WAC 182-538-071;(c) WAC 182-538-096; and(d) WAC 182-53…

The notice requirements in chapter 182-518 WAC apply to integrated managed care (IMC).[Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-170, filed 11/27/19, effective 1/1/20.]

(1) People have medicaid-specific rights when applying for, eligible for, or receiving medicaid-funded health care services.(2) All applicable statutory and constitutional rights apply to all medicaid people including, but not limited to:(a) The participant rights under WAC 246-3…

This section applies to enrollees receiving behavioral health services only (BHSO) under the integrated managed care (IMC) medicaid contract.(1) IMC is mandatory for clients in eligible programs, but the agency may end enrollment or exempt clients from IMC based on WAC 182-538-13…

The medicaid agency's rules related to the authorized use of telemedicine and store and forward technology are found in WAC 182-501-0300 and are applicable to the benefits (including behavioral health services) administered by agency-contracted managed care entities (managed care…

(1) This chapter governs nonmedicaid funded behavioral health services provided under the medicaid agency's behavioral health services wraparound contract. See also chapter 182-538D WAC for rules applicable to nonmedicaid behavioral health services.(2) Washington apple health int…

The following definitions and those found in chapters 182-500 and 182-538 WAC apply to this chapter, unless otherwise stated."Action" means the denial or limited authorization of a service covered under the behavioral health services wraparound contract based on medical necessity…

(1) Introduction. This section contains information about the managed care organization (MCO) grievance and appeal system and the agency's administrative hearing process for enrollees under the behavioral health services wraparound contract in integrated managed care (IMC) region…

Chapter 182-518 WAC applies to notice requirements in integrated managed care (IMC) regional service areas.[Statutory Authority: RCW 41.05.021 and 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538B-170, filed 11/27/19, effective 1/1/20. Statutory Authori…

(1) This chapter governs crisis-related and other behavioral health services provided under the medicaid agency's behavioral health administrative services organization (BH-ASO) contract. See also chapter 182-538D WAC for rules applicable to nonmedicaid behavioral health services…

The definitions in this section and those found in chapters 182-500 and 182-538 WAC apply to this chapter."Action" means the denial or limited authorization of a service covered under the behavioral health administrative services organization (BH-ASO) contract based on medical ne…

(1) For crisis services, the behavioral health administrative services organization (BH-ASO) must determine whether the person receiving the services is eligible for Washington apple health or if the person has any other form of insurance coverage.(2) For people receiving crisis …

(1) General. This section applies to the behavioral health administrative service organization (BH-ASO) grievance system for people within integrated managed care (IMC) regional service areas.(a) The BH-ASO must have a grievance and appeal system to allow a person to file a griev…

(1) Crisis mental health services are intended to stabilize a person in crisis to:(a) Prevent further deterioration;(b) Provide immediate treatment and intervention in a location best suited to meet the needs of the person; and(c) Provide treatment services in the least restricti…

(1) Chemical dependency detoxification services are provided to a person to assist in the process of withdrawal from psychoactive substances in a safe and effective manner.(2) A facility providing detoxification services to a person must:(a) Be a facility licensed by the departme…

(1) A behavioral health administrative services organization (BH-ASO) must appoint advisory board members and maintain an advisory board in order to:(a) Promote active engagement with people with behavioral health disorders, their families, and behavioral health agencies; and(b) …

The following definitions and those found in chapters 182-500, 182-538, and 182-538C WAC apply to this chapter. If conflict exists, this chapter takes precedence."Adult" means a person age 18 or older."Assessment" means the process of obtaining all pertinent bio-psychosocial info…

(1) If a currently operating behavioral health administrative service organization (BH-ASO) chooses to stop functioning as a BH-ASO, fails to perform contract requirements and fails to correct the issue to the medicaid agency's satisfaction when corrective action is issued, or do…

A behavioral health administrative service organization (BH-ASO), or a managed care organization (MCO), or a BH-ASO's or MCO's designee must provide public information on the availability of mental health and substance use disorder services. The BH-ASO or MCO must:(1) Maintain in…

(1) A behavioral health administrative service organization (BH-ASO) and managed care organization (MCO) must develop and implement age and culturally competent behavioral health services that are consistent with chapters 71.24, 71.05, and 71.34 RCW.(2) For involuntary evaluation…

Behavioral health administrative service organizations (BH-ASOs) are responsible for administration of the Mental Health Involuntary Treatment Act and Substance Use Disorders Involuntary Treatment Act, including investigation, detention, transportation for people not eligible for…

A behavioral health administrative service organization (BH-ASO) and managed care organization (MCO) must have a quality plan for continuous quality improvement in the delivery of culturally competent behavioral health services. See WAC 182-538-140 for MCOs and WAC 182-538C-040 f…

The managed care organization (MCO) must:(1) Ensure that each person receiving nonemergency behavioral health rehabilitation services has a primary behavioral health provider who is responsible to carry out the individual service plan; and(2) Allow people, parents of people age t…

In order to enhance and facilitate the department of corrections' ability to carry out its responsibility of planning and ensuring community protection, mental health records and information, as defined in this section, that are otherwise confidential shall be released by any men…

Many records and reports are updated on a regular or as needed basis. The scope of the records and reports to be released to the department of corrections are dependent upon the reason for the request.(1) For the purpose of a presentence investigation release only the most recent…

The mental health service provider will provide the requested relevant records, reports and information to the authorized department of corrections person in a timely manner, according to the purpose of the request:(1) Presentence investigation - Within seven days of the receipt …

The written request for relevant records, reports and information must include:(1) Verification that the person for whom records, reports and information are being requested is under the authority of the department of corrections, per chapter 9.94A RCW, and the expiration date of…