Washington Administrative Code

(1) The medicaid agency requires providers to obtain prior authorization for certain medical equipment and services before delivering the equipment or service to the client, except for dual-eligible medicare/medicaid clients when medicare is the primary payer. The equipment or se…

(1) The medicaid agency limits the amount, frequency, or duration of certain medical equipment and related services, and reimburses up to the stated limit without requiring prior authorization.(2) Certain items have limitations on quantity and frequency. These limits are designed…

(1) The expedited prior authorization process (EPA) is designed to eliminate the need for written and telephonic requests for prior authorization for selected medical equipment procedure codes.(2) The medicaid agency requires a provider to create an authorization number for EPA f…

(1) A provider must not bill the medicaid agency for the rental or purchase of medical equipment supplied to the provider at no cost by suppliers or manufacturers.(2) The agency does not pay a medical equipment provider for medical supplies used in conjunction with a physician of…

If a fee-for-service (FFS) client enrolls in a medicaid agency-contracted managed care organization (MCO), the following apply:(1) The agency stops paying for any rented medical equipment on the last day of the month preceding the month in which the client becomes enrolled in the…

If a client is eligible for both medicare and medicaid, see WAC 182-502-0110 Conditions of payment and prior authorization requirements—Medicare coinsurance, copayments, and deductibles.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-06-025, § 182-543-8200, filed 2/22/2…

(1) The medicaid agency pays qualified providers who meet all conditions in WAC 182-502-0100 for medical equipment, repairs, and related services provided on a fee-for-service (FFS) basis as follows:(a) To agency-enrolled medical equipment providers, qualified complex rehabilitat…

(1) The medicaid agency covers the vision care services listed in this chapter for clients age twenty and younger, according to agency rules and subject to the limitations and requirements in this chapter. The agency pays for vision care when it is:(a) Covered;(b) Within the scop…

The following definitions and those found in chapter 182-500 WAC apply to this chapter. Unless otherwise defined in this chapter, medical terms are used as commonly defined within the scope of professional medical practice in the state of Washington."Blindness" - A diagnosis of v…

This section applies to eligible persons who are twenty years of age and younger.(1) Vision care is available to persons who are eligible for services under one of the Washington apple health programs listed in the table in WAC 182-501-0060 or are eligible for the alien emergency…

(1) Enrolled/contracted eye care providers must:(a) Meet the requirements in chapter 182-502 WAC;(b) Provide only those services that are within the scope of the provider's license;(c) Obtain all hardware (including the tinting of eyeglass lenses) and contact lenses for clients f…

See WAC 182-531-1000 Ophthalmic services.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0250, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0250, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11…

(1) The medicaid agency covers eyeglasses once every twelve months for clients when the following clinical criteria are met:(a) The client has a stable visual condition;(b) The client's treatment is stabilized;(c) The prescription is less than eighteen months old; and(d) One of t…

(1) The medicaid agency covers durable or flexible frames when the client has a diagnosed medical condition that contributes to broken eyeglass frames. To receive payment, the provider must order the "durable" or "flexible" frames through the agency's designated supplier.(2) The …

(1) The medicaid agency covers the following plastic scratch-resistant eyeglass lenses:(a) Single vision lenses;(b) Round or flat top D-style bifocals;(c) Flat top trifocals;(d) Slab-off and prism lenses (including Fresnel lenses);(e) Plastic photochromatic lenses when the client…

(1) The medicaid agency covers contact lenses as the client's primary refractive correction method when the client has a spherical correction of plus or minus 6.0 diopters or greater in at least one eye. See subsection (4) of this section for exceptions to the plus or minus 6.0 d…

See WAC 182-531-1000 Opthalmic services.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0500, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-…

See WAC 182-531-1000 Ophthalmic services.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-14-067, § 182-544-0550, filed 6/29/17, effective 7/30/17. WSR 11-14-075, recodified as § 182-544-0550, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11…

(1) The medicaid agency requires providers to obtain authorization for covered vision care services as required in this chapter.(a) For prior authorization (PA), a provider must submit a written request to the agency as specified in the agency's published vision care billing inst…

(1) The agency does not cover the following:(a) Executive style eyeglass lenses;(b) Bifocal contact lenses;(c) Daily and two week disposable contact lenses;(d) Extended wear soft contact lenses, except when used as therapeutic contact bandage lenses or for aphakic clients;(e) Cus…

(1) To receive payment, vision care providers must bill the agency according to this chapter, chapters 182-501 and 182-502 WAC, and the medicaid agency's published billing instructions and numbered memoranda.(2) The agency pays one hundred percent of the agency contract price for…

(1) The following health professionals may enroll with the medicaid agency, as defined in WAC 182-500-0010, to provide outpatient rehabilitation (which includes occupational therapy, physical therapy, and speech therapy) within their scope of practice to eligible clients:(a) A ph…

(1) Habilitative services assist the client in partially or fully attaining, learning, maintaining, or improving developmental-age appropriate skills that were not fully acquired as a result of a congenital, genetic, or early acquired health condition. To the extent practical, ha…

(1) This section describes:(a) Neurodevelopmental centers that may be reimbursed by the agency;(b) Clients who may receive covered services at a neurodevelopmental center; and(c) Covered services for which a neurodevelopmental center may be reimbursed.(2) In order to provide and …

See WAC 182-546-0100 through 182-546-4300 for ambulance transportation and WAC 182-546-5000 through 182-546-6200 for brokered/nonemergency transportation.[Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0050…

(1) The provisions of this chapter take precedence with respect to ambulance services in cases of ambiguity in, or conflict with, other agency rules governing eligibility for health care services.(2) The medicaid agency covers emergency and nonemergency ambulance transportation t…

The following definitions and those found in chapter 182-500 WAC apply to ambulance transportation services."Advanced life support (ALS)" - See RCW 18.73.030."Advanced life support (ALS) assessment" - Means an assessment performed by ALS trained personnel as part of an emergency …

(1) Clients are eligible for ambulance transportation to covered services subject to the requirements and limitations in this chapter.(a) Clients in the following programs are eligible for ambulance services within Washington state or bordering cities only, as designated in WAC 1…

(1) The ambulance program is a medical transportation service. The medicaid agency pays for ambulance transportation to and from covered medical services when the transportation is:(a) Within the scope of an eligible client's medical care program (see WAC 182-501-0060);(b) Medica…

(1) The medicaid agency does not cover ambulance services when the transportation is:(a) Not medically necessary based on the client's condition at the time of service (see exception at WAC 182-546-1000);(b) Refused by the client (see exception for ITA clients in WAC 182-546-4100…

(1) Ambulances must be licensed, operated, and equipped according to applicable federal, state, and local statutes, ordinances and regulations. An air ambulance provider must have a current Federal Aviation Administration (FAA) air carrier operating certificate, or have a contrac…

(1) In accordance with WAC 182-502-0100(8), the agency pays providers the lesser of the provider's usual and customary charges or the maximum allowable rate established by the agency. The agency's fee schedule payment for ambulance services includes a base rate or lift-off fee pl…

(1) The medicaid agency does not pay separately for ambulance transportation when a client remains as an inpatient client at the admitting hospital and the transportation to or from another facility is for diagnostic or treatment services (e.g., MRI scanning, kidney dialysis). Tr…

(1) The medicaid agency pays for two levels of service for ground ambulance transportation: Basic life support (BLS) and advanced life support (ALS):(a) A BLS ambulance trip is one in which the client receives basic, noninvasive medical services at the scene, point-of-pickup, or …

(1) When more than one client is transported in the same ground ambulance at the same time, the medicaid agency:(a) Pays the ambulance providers at a reduced base rate for the second client who is being transported in the ambulance for medical treatment. This rate is set at seven…

(1) The ground emergency medical transportation (GEMT) program permits publicly owned or operated providers to receive cost-based payments for emergency ground ambulance transportation of clients as described in subsection (2) of this section.(2) This program is for clients under…

(1) Participation in the program by a GEMT provider is voluntary.(2) To qualify under this program and receive supplemental payments, a participating provider must:(a) Provide ground emergency transportation services to clients as described in WAC 182-546-0510(2).(b) Be publicly …

(1) The agency makes supplemental payments for the uncompensated and allowable costs incurred while providing GEMT services to clients, as defined by the United States Office of Management and Budget (OMB).(a) The amount of supplemental payments, when combined with the amount rec…

(1) Each participating provider is responsible for submitting claims to the agency for services provided to eligible clients. Participating providers must submit the claims according to the rules and billing instructions in effect at the time the service is provided.(2) On an ann…

(1) The agency pays an interim supplemental payment for GEMT. These payments using the interim supplemental payment allows the agency to pay participating providers for GEMT. The payments will approximate the GEMT costs eligible for federal financial participation claimed through…

(1) The agency reconciles each interim supplemental payment for GEMT to the provider's filed cost report for the service year in which interim supplemental payments are made.(2) The agency compares the total medicaid-allowable costs to the interim supplemental payments paid to th…

In addition to the health care record requirements in WAC 182-502-0020, GEMT participating providers must also maintain records of accounting procedures and practices that reflect all direct and indirect costs, of any nature, spent performing GEMT services.[Statutory Authority: R…

(1) The agency may conduct audit or investigation activities, as described under chapters 74.09 RCW and 182-502A WAC, to determine compliance with the rules and regulations of the core provider agreement, as well as of the GEMT program.(2) If an audit or investigation is initiate…

When billing the medicaid agency for ambulance trips, ambulance providers must use procedure code modifiers.[Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0600, filed 8/6/20, effective 9/6/20. WSR 11-14-07…

(1) The medicaid agency pays for air ambulance transportation for clients only when all of the following conditions are met:(a) The client's medical condition requires immediate and rapid transportation beyond what ground ambulance can provide;(b) The client's destination is an a…

(1) The medicaid agency pays for emergency ambulance transportation provided to clients who are in another state or U.S. territory according to the provisions of WAC 182-501-0180, 182-501-0182, and 182-502-0120.(2) To receive payment from the agency, an out-of-state ambulance pro…

The medicaid agency does not pay for ambulance transportation for eligible clients traveling outside of the United States and U.S. territories. See WAC 182-501-0184 for ambulance coverage in British Columbia, Canada.[Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017…

(1) The medicaid agency pays for nonemergency ground ambulance transportation when a client is transferred to a higher level facility, or when all of the following requirements are met:(a) The ambulance transportation is medically necessary. See subsection (3) of this section for…

(1) The medicaid agency pays for a nonemergency air ambulance transport only when the transport is prior authorized by the agency.(2) The agency authorizes a nonemergency air ambulance transport only when the following conditions are met:(a) The client's destination is an acute c…

(1) The medicaid agency does not pay for a client's ambulance transportation to an out-of-state treatment facility when the medical service, treatment, or procedure sought by the client is available from an in-state facility or in a designated bordering city, whether or not the c…