Washington Administrative Code

Clients requesting private duty nursing through fee-for-service must submit a complete signed medically intensive children's program (MICP) application (DSHS form 15-398). The MICP application must include the following:(1) DSHS 14-012 consent form;(2) DSHS 14-151 request for DDC…

(1) Private duty nursing when provided through fee-for-service requires prior authorization from the department of social and health services/developmental disabilities community services (DSHS/DDCS).(2) DSHS/DDCS authorizes requests for private duty nursing on a case-by-case bas…

(1) The respiratory care, equipment, and supplies described in this chapter applies to:(a) Medicaid clients who require respiratory care in their homes, community residential settings, and skilled nursing facilities;(b) Providers who supply respiratory care to medicaid clients; a…

The following definitions and those in chapter 182-500 WAC apply to this chapter."Adult family home" - A residential home licensed to care for up to six residents that provides rooms, meals, laundry, supervision, assistance with activities of daily living, and personal care. In a…

(1) To receive respiratory care, a person must be eligible for one of the Washington apple health programs listed in the table in WAC 182-501-0060 or be eligible for the alien emergency medical (AEM) program (as described in WAC 182-507-0110).(2) Persons who are enrolled in an ag…

For eligible clients who reside in skilled nursing facilities, boarding homes, and adult family homes:(1) The medicaid agency pays, according to the requirements in this chapter, for the chronic use of medically necessary respiratory care.(2) The medicaid agency does not pay sepa…

(1) To receive payment for respiratory care equipment and supplies under this chapter, a provider must:(a) Meet the general provider requirements in chapter 182-502 WAC;(b) Obtain prior authorization from the medicaid agency, if required, before delivery to the client and before …

(1) When a provider delivers equipment directly to the client or the client's authorized representative, the provider must furnish the proof of delivery when the medicaid agency requests that information.(2) The medicaid agency requires the proof of delivery to:(a) Be signed and …

(1) The medicaid agency covers, without prior authorization, the rental of an apnea monitor (cardiorespiratory monitor) with recording feature for a maximum of six months when:(a) The client is less than one year of age and meets at least one of the following clinical criteria:(i…

(1) The medicaid agency covers, without prior authorization, one continuous positive airway pressure (CPAP) device including related supplies, per client, every five years. The CPAP device must have a data card and the client must meet the following clinical criteria:(a) The clie…

The agency covers the purchase of a mandibular advancement device for a client when the provider determines that the use of a continuous positive airway pressure (CPAP) device is medically contraindicated or the client cannot medically tolerate a CPAP device. Prior authorization …

(1) The medicaid agency covers, without prior authorization, one bi-level respiratory assist device (RAD), with or without a back-up rate feature, per client every five years. The client must have a clinical disorder characterized as one of the following and meet the clinical cri…

Chest physiotherapy (CPT), which is also known as percussion and postural drainage (P/PD), is traditionally seen as the standard of care of secretion clearance methods. There are client instances when conventional manual CPT is unavailable, ineffective, or not tolerated. The medi…

(1) The medicaid agency covers, without prior authorization, the purchase of a nebulizer and related compressor, with limits, when the following medicare clinical criteria are met.(a) Small volume nebulizer and related compressor for the administration of inhalation drugs for:(i)…

Inhalation drugs and solutions are included in the medicaid agency's prescription drug program. Refer to chapter 182-530 WAC.[Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-0700, filed 6/25/12, effective 8/1/12.]

(1) The medicaid agency covers oxygen and oxygen equipment as provided in this chapter.(2) The agency pays for the rental of a stationary oxygen system and/or a portable oxygen system, as follows:(a) For clients, age 20 and younger, when prescribed by the client's treating practi…

(1) The medicaid agency covers the purchase of oximeters for clients eighteen years of age and older with prior authorization as follows:(a) One standard oximeter, per client, every twenty-four months; or(b) One enhanced oximeter, per client, every thirty-six months. (2) The medi…

(1) The medicaid agency covers the rental of a ventilator, equipment, and disposable ventilator supplies when the client requires periodic or continuous mechanical ventilation for the treatment of chronic respiratory failure resulting from hypoxemia or hypercapnia.(2) The agency'…

(1) The medicaid agency covers suction pumps and supplies when medically necessary for airway clearance or tracheostomy suctioning.(2) The medicaid agency pays for a maximum of two suction devices per client in a five-year period as follows:(a) The medicaid agency rents one prima…

(1) The medicaid agency pays for respiratory care only when listed as covered in this chapter. In addition to the noncovered services found in WAC 182-501-0070, the medicaid agency does not cover:(a) Emergency or stand-by oxygen systems;(b) Portable nebulizers;(c) Kits and concen…

(1) The medicaid agency requires providers to obtain authorization for covered respiratory care as required in this chapter, chapters 182-501 and 182-502 WAC, and in published agency medicaid provider guides and/or provider notices or when the clinical criteria required in this c…

(1) The medicaid agency requires providers to obtain prior authorization for certain items and services before delivering that item or service to the client, except when the items and services are covered by a third-party payer. The item or service must also be delivered to the c…

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

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

(1) The medicaid agency pays qualified providers who meet all of the conditions in WAC 182-502-0100, for covered respiratory care provided on a fee-for-service (FFS) basis as follows:(a) To medicaid agency-enrolled medical equipment and supplies providers, pharmacies, and home he…

(1) The medicaid agency bases the decision to rent or purchase respiratory care equipment and supplies for a client, or pay for repairs and associated labor for client-owned equipment, on cost and on the length of time the client needs the equipment.(2) A provider must not bill t…

(1) The medicaid agency sets, evaluates, and updates the maximum allowable fees for respiratory care equipment and supplies at least once yearly, unless otherwise directed by the legislature or determined necessary by the agency.(2) The agency sets the rates for medical equipment…

The medicaid agency's home infusion therapy and parenteral nutrition program provides the supplies and equipment necessary for parenteral infusion of therapeutic agents to Washington apple health clients. An eligible client receives equipment, supplies, and parenteral administrat…

The following terms and definitions apply to the home infusion therapy/parenteral nutrition program:"Infusion therapy" means the provision of therapeutic agents or nutritional products to individuals by parenteral infusion for the purpose of improving or sustaining a client's hea…

(1) To receive home infusion therapy and parenteral nutrition, subject to the limitations and restrictions in this section and other applicable WAC, a person must be eligible for one of the Washington apple health programs listed in the table in WAC 182-501-0060.(2) Persons enrol…

(1) Eligible providers of home infusion supplies and equipment and parenteral nutrition solutions must:(a) Have a signed core provider agreement with the medicaid agency; and(b) Be one of the following provider types:(i) Pharmacy provider;(ii) Durable medical equipment (DME) prov…

(1) The home infusion therapy and parenteral nutrition program covers the following for eligible clients, subject to the limitations and restrictions listed:(a) A one-month supply of home infusion, per client, per calendar month.(b) A one-month supply of parenteral nutrition solu…

(1) The agency covers the enteral nutrition products, equipment, and related supplies listed in this chapter, according to medicaid agency rules and subject to the limitations and requirements in this chapter.(2) The agency pays for covered enteral nutrition products, equipment a…

The following terms and definitions and those found in chapter 182-500 WAC apply to this chapter:"BMI" see "body mass index.""Body mass index (BMI)" - Means a number that shows body weight relative to height, and is calculated using inches and pounds or meters and kilograms."Diet…

(1) To receive oral or tube-delivered enteral nutrition products, equipment, and related supplies, a person must be eligible for one of the Washington apple health programs under WAC 182-501-0060 or be eligible for the alien emergency medical (AEM) program under WAC 182-507-0110.…

(1) The following providers are eligible to enroll or contract with the medicaid agency to provide orally administered and tube-delivered enteral nutrition products, equipment, and related supplies:(a) A pharmacy provider; or(b) A durable medical equipment provider.(2) To receive…

(1) Subject to the prior authorization requirements and limitations in this section, and in the Enteral Nutrition Program Billing Guide, the agency covers orally administered enteral nutrition products for clients age twenty and younger.(2) The agency's enteral nutrition program …

(1) The medicaid agency covers, with prior authorization (PA) thickeners for clients with dysphagia who are younger than age one. The request for PA must include:(a) Proof the client has dysphagia as documented by a speech therapist or an occupational therapist that specializes i…

(1) The medicaid agency covers orally administered enteral nutrition products, equipment and related supplies for clients who have amino acid, fatty acid, and carbohydrate metabolic disorders, including phenylketonuria (PKU), if the client requires a specialized nutrition product…

(1) General. The agency covers tube-delivered enteral nutrition products, equipment, and related supplies, regardless of age if the client:(a) Has a valid prescription under WAC 182-554-400, which must be submitted within three months of the date the prescriber signed the prescri…

(1) General.(a) Providers must obtain authorization for all covered orally administered or tube-delivered enteral nutrition products, equipment and related supplies as required in this chapter, the agency's published billing instructions, and when the clinical criteria in this ch…

(1) The medicaid agency does not cover the following:(a) Nonmedical equipment, supplies, and related services (for example, backpacks, pouches, bags, baskets, or other carrying containers); and(b) Orally administered enteral nutrition products for any client age 21 and older.(2) …

(1) The medicaid agency:(a) Determines reimbursement for enteral nutrition products, equipment, and related-supplies according to a set fee schedule;(b) Considers medicare's current fee schedule when determining maximum allowable fees;(c) Considers vendor rate increases or decrea…

The medical nutrition therapy program ensures that clients have access to medically necessary outpatient medical nutrition therapy and associated follow-ups.[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-060, § 182-555-0100, filed 10/31/18, effective 1/1/19.]

The following definitions and those found in chapter 182-500 WAC apply to this chapter:"Enteral nutrition" - See WAC 182-554-200."Medical nutrition therapy" - Means an interaction between the registered dietitian (RD) and the client or client's guardian for the purpose of evaluat…

(1) The medicaid agency covers medical nutrition therapy for clients who are referred to a registered dietitian for medical nutrition therapy by a physician, physician assistant (PA), or an advanced registered nurse practitioner (ARNP).(2) For clients age 20 and younger, see the …

Medical nutrition therapy services must be delivered by a registered dietitian (RD) who:(1) Has a current core provider agreement with the medicaid agency; and(2) Has a national provider identifier (NPI).[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-22-060, § 182-555-…

(1) The medicaid agency covers medically necessary medical nutrition therapy when related to a nutrition-related diagnosis for eligible clients, as described under WAC 182-555-0300.(2) The agency covers medical nutrition therapy, nutrition assessment, and counseling for condition…

In addition to the health care record requirements found in WAC 182-502-0020, the medical nutrition therapy provider must maintain the following documentation in the client's file:(1) Referral from the provider, as described under WAC 182-555-0300;(2) The medical nutrition therap…

(1) The medicaid agency covers chiropractic services for clients age 20 and younger only. Providers must follow the rules for the early period screening, diagnosis, and treatment (EPSDT) program, see chapter 182-534 WAC.(2) To be paid, chiropractic services must be:(a) Provided b…