Washington Administrative Code

(1) The director, in consultation with the participating state agencies, appoints vacant committee positions from a pool of interested applicants. Interested persons are provided an opportunity to submit applications to the director for consideration.(2) When appointing committee…

(1) As a continuing condition of appointment, committee members must:(a) Not have a substantial financial conflict of interest, such as an interest in a health technology company, including the holding of stock options, or the receipt of honoraria, or consultant moneys;(b) Comple…

(1) The committee may establish bylaws, within applicable statutory and regulatory requirements, to govern the orderly resolution of the committee's purposes. Proposed bylaw amendments are published on the centralized, internet-based communication tool at least fourteen calendar …

(1) In making a coverage determination, committee members shall review and consider evidence regarding the safety, efficacy, and cost-effectiveness of the technology as set forth in the health technology assessment. The committee also considers other information it deems relevant…

The committee shall:(1) Determine the conditions, if any, under which the health technology will be included as a covered benefit in health care programs of participating agencies by deciding that:(a) Coverage is allowed without special conditions because the evidence is sufficie…

This section applies to all final coverage determinations made after August 1, 2016.(1) The health care authority reviews the final coverage determination for conflicts identified in RCW 70.14.120 (1)(a) and (b).(2) The health care authority reviews whether the health technology …

Nothing in this chapter limits the superior court's inherent authority to review health technology clinical committee determinations to the extent of assuring the decisions are not arbitrary, capricious, or contrary to law.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 16…

(1) The committee chair, upon an affirmative vote of the committee members, may establish ad hoc temporary advisory groups under RCW 70.14.110 (2)(c). At the time an ad hoc temporary advisory group is formed, the committee must state the ad hoc temporary advisory group's objectiv…

(1) The director, in consultation with participating agencies and the committee, selects health technologies to be reviewed or rereviewed by the committee.(2) The director or committee may also consider petitions requesting initial review of a health technology from interested pa…

(1) Upon providing notice on the centralized, internet-based communication tool required by RCW 70.14.100 (1)(b) that the health technology has been selected for review, the director shall post an invitation for interested parties to submit information relevant to the health tech…

The medicaid agency pays for hospital services provided to eligible clients when:(1) The eligible client is a patient in an acute care hospital and the hospital meets the definition of hospital or psychiatric hospital in RCW 70.41.020, chapter 182-500 or WAC 182-550-1050;(2) The …

The following definitions and abbreviations, those found in chapter 182-500 WAC, Medical definitions, and definitions and abbreviations found in other sections of this chapter apply to this chapter. When a term is not defined in this chapter, other agency or agency's designee WAC…

(1) The medicaid agency:(a) Pays for an eligible Washington apple health client's admission to a hospital only when the client's attending physician orders admission and when the admission and treatment provided:(i) Are covered under WAC 182-501-0050, 182-501-0060 and 182-501-006…

A hospital covered service provided to a person eligible under a Washington apple health (WAH) program that is paid by the agency's fee-for-services payment system must be within the scope of the person's WAH program. Coverage restriction includes, but is not limited to the follo…

(1) Revenue code categories and subcategories listed in this chapter are published in the UB-92 or UB-04 National Uniform Billing Data Element Specifications Manual.(2) The medicaid agency requires a hospital provider to report and bill all hospital services provided to Washingto…

(1) The medicaid agency requires an outpatient hospital provider to report the appropriate current procedural terminology (CPT) or health care common procedure coding system (HCPCS) codes in addition to the required revenue codes on an outpatient claim line when using any of the …

Subject to the limitations and restrictions listed, this section identifies covered and noncovered revenue code categories and subcategories for inpatient hospital services.(1) The medicaid agency pays for an inpatient hospital covered service in the following revenue code catego…

(1) The medicaid agency pays for an outpatient hospital covered service in the following revenue code categories and subcategories when the hospital provider accurately bills:(a) "Pharmacy," only subcategories "general classification," "generic drugs," "nongeneric drugs," "drugs …

The medicaid agency does not pay for an inpatient or outpatient hospital service, treatment, equipment, drug, or supply that is not listed or referred to as a covered service in this chapter. The following list of noncovered items and services is not intended to be all-inclusive.…

Refer to WAC 182-502-0022 for the payment policy for provider preventable conditions.[Statutory Authority: 42 C.F.R. § 447.26. WSR 13-11-051, § 182-550-1650, filed 5/14/13, effective 7/1/13. WSR 11-14-075, recodified as § 182-550-1650, filed 6/30/11, effective 7/1/11. Statutory A…

(1) This section applies to the agency's authorization and utilization review (UR) of inpatient and outpatient hospital services provided to Washington apple health (medicaid) clients receiving services through the fee-for-service program. For clients enrolled in an agency-contra…

The medicaid agency pays for certain specialty services without requiring prior authorization when such services are provided consistent with agency medical necessity and utilization review standards. These services include, but are not limited to, the following:(1) All transplan…

(1) The medicaid agency pays for medically necessary transplant procedures only for eligible Washington apple health clients. Clients eligible under the alien emergency medical (AEM) program are not eligible for transplant coverage.(2) The agency covers the following transplant p…

This section applies to requirements for facilities that perform the medicaid agency-approved transplants described in WAC 182-550-1900(2).(1) The agency requires instate transplant facilities to meet the following requirements to be paid for transplant services provided to Washi…

(1) The medicaid agency pays a hospital for bariatric surgery and bariatric surgery-related services only when the surgery is provided in an inpatient hospital setting and only when:(a) The client:(i) Qualifies for bariatric surgery by successfully completing all requirements und…

(1) The medicaid agency pays a hospital that is specifically approved by the agency to provide inpatient chronic pain management services, an all-inclusive per diem facility fee. The agency pays professional fees for chronic pain management services to performing providers under …

See chapter 182-551 WAC Alternatives to hospital services, subchapter I—Hospice services.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-2431, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2431, filed 6/30/11, effective 7/1/1…

(1) The medicaid agency pays hospice agencies participating in the Washington apple health program for general inpatient and inpatient respite services provided to clients in hospice care, when:(a) The hospice agency coordinates the provision of the inpatient services; and(b) The…

Acute physical medicine and rehabilitation (acute PM&R) is a twenty-four-hour inpatient comprehensive program of integrated medical and rehabilitative services provided during the acute phase of a client's rehabilitation. The medicaid agency requires prior authorization for acute…

(1) Only a client who is eligible for one of the Washington apple health programs may receive acute PM&R services, subject to the restrictions and limitations in this section and WAC 182-550-2501, 182-550-2511, 182-550-2531, 182-550-2541, 182-550-2551, 182-550-2561, 182-550-3381,…

(1) Before August 1, 2007, only an in-state or bordering city hospital may apply to become a medicaid agency-approved acute PM&R hospital. After July 31, 2007, an in-state, bordering city or critical border hospital may apply to become an agency-approved acute PM&R hospital. To a…

(1) To ensure quality of care, the medicaid agency may conduct reviews (e.g., post-pay, on-site) of any agency-approved acute PM&R hospital. (2) A provider of acute PM&R services must act on any report of substandard care or violation of the hospital's medical staff bylaws and CA…

(1) Acute PM&R services may be authorized when all of the following are met:(a) The client has all of the following:(i) Extensive or complex medical needs;(ii) Nursing needs; and(iii) Therapy needs.(b) The client has a new or recent significant impairment in two or more of the fo…

(1) The medicaid agency requires prior authorization for acute PM&R services. The acute PM&R provider of services must obtain prior authorization:(a) Before admitting a client to the rehabilitation unit; and(b) For an extension of stay before the client's current authorized perio…

The long-term acute care (LTAC) program is a twenty-four-hour inpatient comprehensive program of integrated medical and rehabilitative services provided in a medicaid agency-approved LTAC hospital during the acute phase of a client's care. The agency requires prior authorization …

Only a client who is eligible for one of the following programs may receive LTAC services, subject to the restrictions and limitations in WAC 182-550-1050, 182-550-2565, 182-550-2580, 182-550-2585, 182-550-2590, 182-550-2595, 182-550-2596, and other rules:(1) Categorically needy …

(1) To apply to become a medicaid agency-approved long-term acute care (LTAC) hospital, the agency requires a hospital to:(a) Submit a letter of request to:LTAC Program ManagerDivision of Health Care ServicesHealth and Recovery Services AdministrationP.O. Box 45506Olympia WA 9850…

(1) To ensure quality of care, the medicaid agency may conduct post-pay or on-site reviews of any agency-approved LTAC hospital. See chapter 182-502A WAC for additional information on audits conducted by agency staff.(2) A provider of LTAC services must act on any reports of subs…

(1) The medicaid agency requires prior authorization for Level 1 and Level 2 long term acute care (LTAC) inpatient stays. The prior authorization process includes all the following:(a) For an initial 30-day stay:(i) The client must:(A) Be eligible under one of the programs listed…

(1) In addition to room and board, the LTAC fixed per diem rate includes, but is not limited to, the following (see the medicaid agency's LTAC billing instructions for applicable revenue codes):(a) Room and board - Rehabilitation;(b) Room and board - Intensive care;(c) Pharmacy -…

(1) The medicaid agency uses the ratio of costs-to-charges (RCC) payment method to pay an LTAC hospital for the following that are not included in the LTAC fixed per diem rate:(a) Pharmacy - After the first two hundred dollars per day in total allowed covered charges for any comb…

(1) The following definitions and abbreviations and those found in chapter 182-500 WAC and WAC 182-182-1050 apply to this section:(a) "CAH" see "critical access hospital."(b) "Cost settlement" means a reconciliation of the fee-for-service interim CAH payments with a CAH's actual …

(1) The medicaid agency or the agency's designee pays for covered inpatient psychiatric services for eligible Washington apple health clients.(2) The definitions found in chapter 182-500 WAC and WAC 182-550-1050 apply to this section.(3) To be paid for an inpatient psychiatric ad…

(1) Effective for dates of admission from July 1, 2005, through June 30, 2007, and in accordance with legislative directive, the agency implemented two separate base community psychiatric hospitalization payment rates, one for medicaid and children's health insurance program (CHI…

For discharge planning service requirements, see chapter 246-320 WAC.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-19-018, § 182-550-2750, filed 9/8/23, effective 10/9/23. WSR 11-14-075, recodified as § 182-550-2750, filed 6/30/11, effective 7/1/11. Statutory Authorit…

(1) Eligibility for payment. To be eligible for payment for covered inpatient hospital services, a hospital must:(a) Have a core-provider agreement with the medicaid agency; and(b) Be an in-state hospital, a bordering city hospital, a critical border hospital, or a distinct unit …

(1) Introduction. The rules in this section establish the medicaid agency's payment policy for inpatient claims for provider preventable fourteen-day readmissions and do not apply to any other rules regarding payment for hospital admissions.(2) Applicability. The rules in this se…

(1) The medicaid agency uses the diagnosis-related group (DRG) payment method to pay for covered inpatient hospital services, except as specified in WAC 182-550-4300 and 182-550-4400.(2) The agency assigns a DRG code to each claim for an inpatient hospital stay using Solventum™ s…

This section describes the agency's payment method for acute physical medicine and rehabilitation (PM&R) services provided by acute PM&R hospitals.(1) The agency pays an acute PM&R hospital for acute PM&R services based on a rehabilitation per diem rate. See chapter 182-550 WAC a…

(1) The medicaid agency calculates the case-mix index (CMI) for each individual hospital to measure the relative cost for treating medicaid and CHIP cases in a given hospital. The CMI represents the relative acuity of the claims.(2) Using medicaid and children's health insurance …