Washington Administrative Code

The medicaid agency does not pay ambulance providers who meet department of health (DOH) criteria for participation in the statewide trauma network an additional amount for transports involving qualified trauma cases described in WAC 182-550-5450. Subject to the availability of t…

The medicaid agency pays for medically necessary ambulance transportation to and from a covered behavioral health service (see WAC 182-546-4300) subject to the conditions and limitations within this chapter. For purposes of Involuntary Treatment Act (ITA) and voluntary behavioral…

(1) To be considered an Involuntary Treatment Act (ITA) transport, a client's involuntary status must have resulted from:(a) A petition for initial detention filed by a DCR (seventy-two hour hold); and(b) Continued hospitalization (fourteen-day, ninety-day, or one hundred eighty-…

(1) The agency, as payer of last resort, pays the transportation costs for clients that a Washington designated crisis responder (DCR) detains under the ITA on a seventy-two hour initial detention or five-day revocation hold until the client is discharged from the evaluation and …

Chapter 74.70 RCW establishes the quality assurance fee for specified providers of emergency ambulance services through July 1, 2028. The fee is added to base funding from all other sources to support additional medicaid payments. The fee applies to nonpublic and nonfederal provi…

(1) The agency assesses each ambulance transport provider a quality assurance fee to be paid on a quarterly basis.(2) The agency sends each ambulance transport provider an assessment notice or invoice specified due dates.(3) The agency assesses interest and penalties on quality a…

(1) The agency covers nonemergency nonambulance transportation to and from covered health care services, as required by 42 C.F.R. 431.53, subject to the limitations and requirements under WAC 182-546-5000 through 182-546-6200. See WAC 182-546-1000 for nonemergency ground ambulanc…

The following definitions and those found in chapter 182-500 WAC apply to nonemergency medical brokered transportation. Unless otherwise defined in WAC 182-546-5200 through 182-546-6000, medical terms are used as commonly defined within the scope of professional medical practice …

(1) The medicaid agency requires:(a) Brokers and subcontracted transportation providers to be licensed, equipped, and operated in accordance with applicable federal, state, and local laws, and the terms specified in their contracts;(b) Brokers to:(i) Screen their employees and su…

(1) The agency pays for nonemergency transportation for Washington apple health (WAH) clients, including persons enrolled in an agency-contracted managed care organization (MCO), to and from health care services when the health care service(s) meets the requirements in WAC 182-54…

(1) Clients must comply with applicable state, local, and federal laws during transport.(2) Clients must comply with the rules, procedures and policies of the medicaid agency, brokers, the brokers' subcontracted transportation providers, and health care service providers.(3) A cl…

(1) The medicaid agency covers nonemergency transportation for a Washington apple health client to and from health care services if all of the following apply:(a) The health care services are:(i) Within the scope of coverage of the eligible client's benefit services package;(ii) …

(1) The following service categories listed in WAC 182-501-0060 are subject to the following exclusions and limitations:(a) Adult day health (ADH) - Nonemergency transportation for ADH services is not provided through the brokers. ADH providers are responsible for arranging or pr…

(1) The agency does not pay for any costs related to intermediate stops or delays that are not directly related to the original approved trip, including trips that would, or did, result in additional transportation costs due to client convenience.(2) Brokers may authorize interme…

(1) A client receiving services provided under fee-for-service or through a medicaid agency-contracted managed care organization (MCO) may be transported to a local provider only.(a) A local provider's medical specialty may vary as long as the provider is capable of providing med…

(1) The agency reviews requests for out-of-state nonemergency transportation in accordance with regulations for covered health care services including, but not limited to, WAC 182-501-0180, 182-501-0182 and 182-501-0184. Out-of-state requests must be submitted to the agency no le…

(1) The agency may pay for meals and lodging for clients who must be transported to health care services outside of the client's local community. The agency's transportation brokers determine when meals and lodging are necessary based on a client's individual need.(2) Brokers may…

(1) The medicaid agency contracts with brokers to authorize or deny requests for transportation services.(2) Exceptional requests to transport a client may be referred to the agency's medical director or designee for review.(3) Nonemergency medical transportation, other than ambu…

(1) The medicaid agency does not cover nonemergency transportation that is not specifically addressed in WAC 182-546-5000 through 182-546-6200.(2) Brokers do not provide nonemergency transportation for admissions under the Involuntary Treatment Act (ITA), as defined in WAC 182-54…

(1) To be reimbursed for trips, meals, or lodging, the requestor must receive prior authorization from the broker at least two business days in advance of the client's travel.(2) A client must request reimbursement of preauthorized expenditures for trips, meals, or lodging within…

(1) The medicaid agency covers the hearing aids listed in this chapter, according to agency rules and subject to the limitations and requirements in this chapter. See also WAC 182-531-0375 audiology services.(2) The agency pays for hearing aids when:(a) Covered;(b) Within the sco…

The following definitions, the definitions found in RCW 18.35.010, and those found in chapter 182-500 WAC apply to this chapter."Bone-anchored hearing aid" or "bone conduction hearing device" means a type of hearing aid that transmits sound vibrations through bones in the head. T…

(1) Clients covered by one of the Washington apple health programs as listed in the table in WAC 182-501-0060 are eligible for hearing aids and related services.(2) Clients enrolled in a medicaid agency-contracted managed care organization (MCO) must arrange for hearing aid and r…

(1) The medicaid agency covers new, nonrefurbished, monaural or binaural hearing aid(s), which includes the ear molds, for eligible clients age twenty and younger. In order for the provider to receive payment, the hearing aid must meet the client's specific hearing needs and carr…

(1) Nonrefurbished, monaural hearing aids. The medicaid agency covers one new nonrefurbished monaural hearing aid, which includes the ear mold, every five years for clients age twenty-one and older.(a) The client must have an average decibel loss of forty-five or greater in the b…

(1) The medicaid agency does not cover the following items:(a) Tinnitus maskers;(b) Frequency modulation (FM) systems, including the computer-aided hearing devices for FM systems; and(c) Nonprescription hearing aids or similar devices including, but not limited to:(i) Personal so…

(1) Prior authorization is not required for clients age twenty and younger for hearing aid(s) and services.(2) The agency pays for services according to the early and periodic screening, diagnostic, and treatment (EPSDT) provisions, as described in chapter 182-534 WAC. The standa…

(1) The agency requires prior authorization for covered hearing aids when the clinical criteria set forth in this chapter are not met. The agency evaluates these requests on a case-by-case basis to determine whether they are medically necessary, according to the process found in …

(1) The medicaid agency's payment for purchased hearing aids includes all of the following:(a) The audiometric evaluation;(b) An impression for an ear mold;(c) The ear mold;(d) The dispensing fee;(e) A conformity evaluation, if done;(f) Three batteries; and(g) Up to three follow-…

This chapter establishes the medicaid agency's:(1) Requirements for enrollment as a federally qualified health center (FQHC) provider; and(2) Reimbursement methodology for services provided by an FQHC to a Washington apple health client.[Statutory Authority: RCW 41.05.021 and 41.…

This section contains definitions of words or phrases that apply to this chapter. Unless defined in this chapter, the definitions found in chapter 182-500 WAC apply."APM index" - The agency uses the alternative payment methodology (APM) to update APM encounter payment rates on an…

(1) To enroll as a Washington apple health provider and receive payment for services, a federally qualified health center (FQHC) must:(a) Receive FQHC certification for participation in the Title XVIII (medicare) program according to 42 C.F.R. 491;(b) Sign a core provider agreeme…

(1) The following outpatient services qualify for FQHC encounter rate reimbursement:(a) Physician services specified in 42 C.F.R. 405.2412.(b) Nurse practitioner or physician assistant services specified in 42 C.F.R. 405.2414.(c) Clinical psychologist and clinical social worker s…

(1) For services provided during the period beginning January 1, 2001, and ending December 31, 2008, the medicaid agency's payment methodology for federally qualified health centers (FQHC) was a prospective payment system (PPS) as authorized by 42 U.S.C. 1396a (bb)(2) and (3).(2)…

(1) The agency limits FQHC encounter rate reimbursement to one per client, per day except in the following circumstances:(a) There is a subsequent visit in the same cost center that requires separate evaluation and treatment on the same day for unrelated diagnoses; or(b) There ar…

In accordance with 42 U.S.C. 1396a (bb)(3)(B), the agency adjusts its payment rate to a federally qualified health center (FQHC) to take into account any increase or decrease in the scope of the FQHC's services. The procedures and requirements for any such rate adjustment are des…

An overpayment assessment by the agency against an FQHC identified in the annual managed care reconciliation (see WAC 182-548-1450) may be appealed based on WAC 182-502-0230 and RCW 41.05A.170. Administrative hearing appeals are governed by chapter 34.05 RCW (Administrative Proce…

(1) An FQHC provider has a right to an administrative appeal of agency action related to rate setting under this chapter based on the rules in this section.(a) The rules in WAC 182-502-0220 do not apply to appeals of agency action related to rate setting under this chapter.(b) Ap…

This chapter establishes the medicaid agency's reimbursement methodology for rural health clinic (RHC) services. RHC conditions for certification are found in 42 C.F.R. Part 491.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-11-008, § 182-549-1000, filed 5/7/15, effect…

This section contains definitions of words and phrases that apply to this chapter. Unless defined in this chapter, the definitions found in chapter 182-500 WAC apply."APM index" - The agency uses the alternative payment methodology (APM) to update APM encounter payment rates on a…

(1) To participate in the Title XIX (medicaid) program or the Title XXI (CHIP) program and receive payment for services, a rural health clinic (RHC) must:(a) Receive RHC certification for participation in the Title XVIII (medicare) program according to 42 C.F.R. 491;(b) Sign a co…

(1) Rural health clinic (RHC) services are defined under 42 C.F.R. 440.20(b).(2) The medicaid agency pays for RHC services when they are:(a) Within the scope of an encounter-eligible client's benefit package. See WAC 182-501-0060; and(b) Medically necessary as defined in WAC 182-…

(1) For services provided during the period beginning January 1, 2001, and ending December 31, 2008, the medicaid agency's payment methodology for rural health clinics (RHC) was a prospective payment system (PPS) as authorized by 42 U.S.C. 1396a (bb)(2) and (3).(2) For services p…

(1) The medicaid agency limits RHC encounter rate reimbursement to one per client, per day except in the following circumstances:(a) There is a subsequent visit in the same cost center that requires separate evaluation and treatment on the same day for unrelated diagnoses; or(b) …

In accordance with 42 U.S.C. 1396a (bb)(3)(B), the agency adjusts its payment rate to a rural health clinic (RHC) to take into account any increase or decrease in the scope of the RHC's services. The procedures and requirements for any such rate adjustments are described below.(1…

An overpayment assessment by the agency against an RHC that was identified in the annual managed care reconciliation (see WAC 182-549-1450) may be appealed based on WAC 182-502-0230 and RCW 41.05A.170. Administrative hearing appeals are governed by chapter 34.05 RCW (Administrati…

(1) An RHC provider has a right to an administrative appeal of agency action related to rate setting under this chapter based on the rules in this section.(a) The rules in WAC 182-502-0220 do not apply to appeals of agency action related to rate setting under this chapter.(b) App…

Under RCW 70.14.080 through 70.14.140, the director of the Washington state health care authority provides administrative support for, and adopts rules to govern the health technology clinical committee and a health technology assessment program within the health care authority. …

When used in this chapter:(1) "Advisory group" as defined in RCW 70.14.080 means a group established under RCW 70.14.110 (2)(c).(2) "Centralized, internet-based communication tool" means the health care authority's health technology assessment program internet web pages establish…

The purpose of the committee is to make coverage determinations for the participating agencies as described under RCW 70.14.110.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16-18-023, § 182-55-015, filed 8/26/16, effective 9/26/16. Statutory Authority: RCW 41.05.013, 41…