Washington Administrative Code

(1) Effective through June 30, 2019, the medicaid agency:(a) Pays for bariatric surgery provided in designated agency-approved hospitals when all criteria established in WAC 182-550-2301 are met;(b) Requires qualification and prior authorization of the provider before bariatric s…

(1) The rules in this section apply when an eligible client transfers from an acute care hospital or distinct unit to any of the following:(a) Another acute care hospital or distinct unit;(b) A skilled nursing facility (SNF);(c) An intermediate care facility (ICF);(d) Home care u…

(1) The medicaid agency identifies a diagnosis-related group (DRG) high outlier claim based on the claim's estimated costs. The agency allows a high outlier payment for claims paid using the DRG payment method when high outlier criteria are met.(a) To qualify as a DRG high outlie…

The medicaid agency redesigns (rebases) the medicaid inpatient payment system as needed. The base inpatient conversion factor and per diem rates are only updated during a detailed rebasing process, or as directed by the state legislature. Inpatient payment system factors such as …

(1) The medicaid agency updates all of the following components of a hospital's specific diagnosis-related group (DRG) factor and per diem rates at rebase:(a) Wage index adjustment;(b) Direct graduate medical education (DGME); and(c) Indirect medical education (IME).(2) Effective…

(1) The medicaid agency measures the effectiveness of budget neutral rebasing by applying a budget neutrality adjustment factor to the base payment rates for both inpatient and outpatient hospitals as needed to maintain aggregate payments under rebased payment systems.(a) The age…

The agency uses the payment methods described in this section to pay bordering city hospitals and critical border hospitals for inpatient and outpatient claims. Bordering city hospitals and critical border hospitals are defined in WAC 182-550-1050.(1) For inpatient hospital claim…

This section describes the payment methods the agency uses to pay hospitals located out-of-state for providing services to eligible Washington apple health clients. This section does not apply to hospitals located in any of the designated bordering cities listed in WAC 182-501-01…

(1) For rate-setting purposes, the agency considers as new:(a) A hospital which began services after the most recent rebasing; or(b) A hospital that has not been in operation for a complete fiscal year.(2) With the exception of determining psychiatric per diem rates as directed b…

(1) For purposes of this section, a change in hospital ownership may involve one or more, but is not limited to, the following events:(a) A change in the composition of the partnership;(b) A sale of an unincorporated sole proprietorship;(c) The statutory merger or consolidation o…

(1) Except when otherwise specified, inpatient services provided by hospitals and units that are exempt from the diagnosis-related group (DRG) payment method are paid under the ratio of costs-to-charges (RCC) payment method described in WAC 182-550-4500, the per diem payment meth…

(1) Inpatient services are exempt from the diagnosis-related group (DRG) payment method only if they qualify for payment methods specifically mentioned in other sections of this chapter or in this section.(2) Subject to the restrictions and limitations in this section, the agency…

(1) The medicaid agency pays hospitals using the ratio of costs-to-charges (RCC) payment method for services exempt from the following payment methods:(a) Ambulatory payment classification (APC);(b) Diagnosis-related group (DRG);(c) Enhanced ambulatory patient group (EAPG);(d) Pe…

(1) Administrative day rate.(a) The medicaid agency allows hospitals an administrative day rate for those days of hospital stay in which a client does not meet criteria for acute inpatient level of care, but is not discharged because:(i) An appropriate placement outside the hospi…

(1) The medicaid agency's "full cost" public hospital certified public expenditure (CPE) inpatient payment program provides payments to participating government-operated hospitals based on the "full cost" of covered medically necessary services and requires the expenditure of loc…

To meet legislative requirements, the medicaid agency includes a "hold harmless" provision for eligible hospitals participating in certified public expenditure (CPE) payment programs under WAC 182-550-4650 and 182-550-5400. Under the provision and subject to legislative directive…

This section does not apply to psychiatric certified public expenditure (CPE) inpatient hospital admissions. See WAC 182-550-2600.(1) CPE inpatient hospital claims submitted to the medicaid agency must meet all authorization and program requirements in WAC and current agency-publ…

This section does not apply to out-of-state hospitals unless they are border hospitals (critical or noncritical).(1) The medicaid agency:(a) Pays for services provided to a client eligible for a state-administered program (SAP) based on SAP rates;(b) Establishes SAP rates indepen…

(1) As required by Section 1902 (a)(13)(A) of the Social Security Act (42 U.S.C. 1396 (a)(13)(A)) and RCW 74.09.730, the medicaid agency makes payment adjustments to eligible hospitals that serve a disproportionate number of low-income clients. These adjustments are also known as…

To be eligible for disproportionate share hospital (DSH) payments, a new hospital provider must have claims data, audited financial statements, and an "as filed" or finalized medicare cost report for the hospital base year used by the medicaid agency in calculating DSH payments f…

(1) For purposes of eligibility for disproportionate share hospital (DSH) payments, a change in hospital ownership has occurred if any of the criteria in WAC 182-550-4200(1) is met.(2) To be considered eligible for DSH, a hospital whose ownership has changed must notify the medic…

(1) In order to comply with federal law and regulation (42 U.S.C. 1396r-4 (j)(2); 42 C.F.R. Part 455, Subpart D), the medicaid agency contracts with an independent auditor to conduct an annual, independent, certified audit of the agency's disproportionate share hospital (DSH) pay…

(1) The medicaid agency makes low income disproportionate share hospital (LIDSH) payments to qualifying hospitals through the disproportionate share hospital (DSH) program.(2) To qualify for an LIDSH payment, a hospital must:(a) Not be a hospital eligible for public disproportion…

(1) A psychiatric hospital owned and operated by the state of Washington is eligible to receive payments under the institution for mental diseases disproportionate share hospital (IMDDSH) program.(2) For the purposes of the IMDDSH program, the following definitions apply:(a) "Ins…

(1) A hospital is eligible for the medical care services disproportionate share hospital (MCSDSH) payment if the hospital:(a) Meets the criteria in WAC 182-550-4900;(b) Is an in-state or designated bordering city hospital;(c) Provides services to clients eligible under the medica…

(1) The medicaid agency makes small rural disproportionate share hospital (SRDSH) payments to qualifying small rural hospitals through the disproportionate share hospital (DSH) program.(2) To qualify for an SRDSH payment, a hospital must:(a) Not be participating in the "full cost…

(1) Effective July 1, 2011, a hospital is eligible for the children's health program disproportionate share hospital (CHPDSH) payment if funding is legislatively appropriated and if the hospital:(a) Meets the criteria in WAC 182-550-4900;(b) Is an in-state or designated bordering…

(1) The medicaid agency's public hospital disproportionate share hospital (PHDSH) program is a certified public expenditure program for government-operated hospitals. To be eligible for PHDSH, a hospital must qualify for disproportionate share hospital (DSH) payments under WAC 18…

(1) For patients discharged after June 30, 2005, a certified public expenditure (CPE) hospital must annually submit to the medicaid agency federally required medicaid cost report schedules, using schedules approved by the centers for medicare and medicaid services (CMS), that app…

(1) The trauma care fund (TCF) is an amount appropriated to the medicaid agency each state fiscal year (SFY), at the legislature's sole discretion, for the purpose of supplementing the agency's payments to eligible trauma service centers for providing qualified trauma services to…

(1) The medicaid agency will reimburse hospital-based rural health clinics under the prospective payment methods effective July 1, 1994. Under the prospective payment method, the agency will not make reconciliation payments to a hospital-based rural health clinic to cover its cos…

(1) The purpose and intent of this section is to describe how the medicaid agency, pertaining to medicaid hospital rates, will comply with section 4711(a) of the federal Balanced Budget Act of 1997, Public Law 105-33, as codified at 42 U.S.C. 1396a (a)(13)(A).(2) For purposes of …

The dispute resolution process for hospital rate reimbursement follows the procedures as stated in WAC 182-502-0220.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-5600, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-5600, fil…

(1) In-state and border area hospitals will complete and submit a copy of their annual medicare cost reports (HCFA 2552) to the medicaid agency. These hospital providers will:(a) Maintain adequate records for audit and review purposes, and assure the accuracy of their cost report…

The medicaid agency will cover outpatient services, emergent outpatient surgical care, and other emergency care performed on an outpatient basis in a hospital for categorically needy or limited casualty program-medically needy clients.[Statutory Authority: RCW 41.05.021 and 41.05…

(1) The medicaid agency pays hospitals for covered outpatient hospital services provided to eligible clients when the services meet the provisions in WAC 182-550-1700. All professional medical services must be billed according to chapter 182-531 WAC.(2) To be paid for covered out…

(1) The medicaid agency pays for physical therapy provided to eligible clients as an outpatient hospital service according to WAC 182-545-200 and 182-550-6000.(2) A hospital must bill outpatient hospital physical therapy services using appropriate billing codes listed in the agen…

(1) The medicaid agency pays for occupational therapy provided as an outpatient hospital service to eligible clients according to WAC 182-545-200 and 182-550-6000.(2) The hospital must bill outpatient hospital occupational therapy services using appropriate billing codes listed i…

(1) The medicaid agency pays for speech therapy services provided to eligible clients as an outpatient hospital service according to this section and WAC 182-545-200 and 182-550-6000.(2) The agency requires swallowing (dysphagia) evaluations to be performed by a speech/language p…

The medicaid agency will provide outpatient substance use disorder treatment in programs qualified under WAC 182-538C-230 and certified under chapter 246-341 WAC or its successor. See RCW 71.24.385.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 21-18-059, § 182-550-6250, …

See chapter 182-555 WAC for medical nutrition therapy.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-060, § 182-550-6300, filed 10/31/18, effective 1/1/19; WSR 15-18-065, § 182-550-6300, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-6300, …

The medicaid agency may pay for an outpatient weight loss program only when provided through an outpatient weight loss facility approved by the agency. The agency will deny payment for services provided by nonapproved providers.[Statutory Authority: RCW 41.05.021 and 41.05.160. W…

(1) The medicaid agency pays a hospital only for:(a) Blood bank service charges for processing and storage of blood and blood components; and(b) Blood administration charges.(2) The agency does not pay for blood and blood components.(3) The agency does not pay a hospital separate…

See chapter 182-531 WAC regarding rules for inpatient and outpatient physician services.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-18-065, § 182-550-6600, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-6600, filed 6/30/11, effective 7/1/11…

(1) The agency pays:(a) For dates of admission before August 1, 2007, for only emergency care for an eligible medicaid and CHIP client who goes to another state, except specified border cities, specifically for the purpose of obtaining medical care that is available in the state …

(1) The medicaid agency pays for outpatient services using an outpatient prospective payment system (OPPS) for all hospitals that do not qualify as in-state critical access hospitals per WAC 182-550-2598.(2) The agency uses the enhanced ambulatory payment group (EAPG) software pr…

This section describes hospital provider billing requirements and the payment methods the medicaid agency uses to pay for covered outpatient hospital services provided by hospitals included in the outpatient prospective payment system (OPPS).(1) Providers must bill according to n…

(1) The medicaid agency limits payment for covered outpatient hospital services to the current published maximum allowable units of services listed in the outpatient fee schedule published on the agency's website, subject to the following limitations:(a) To receive payment for se…

(1) The medicaid agency uses national relative weights established by 3MTM as part of its enhanced ambulatory patient group (EAPG) payment system.(2) The agency may update the relative weights used for calculating OPPS payments on July 1st of each year, beginning on July 1, 2015.…

The medicaid agency may apply an outpatient prospective payment system (OPPS) budget target adjustor to the enhanced ambulatory patient group (EAPG) payment. The agency calculates the OPPS budget target adjustor based on legislative direction to achieve the legislature's targeted…