A client and/or the client's provider may request the medicaid agency or its designee to pay for a noncovered health care service. This is called an exception to rule (ETR). ETR does not apply to nonformulary drugs (see WAC 182-530-2300
(1) The agency or its designee cannot approve an exception to rule if the requested service is excluded under state statute.
(2) The item or service(s) for which an exception is requested must be of a type and nature which falls within accepted standards and precepts of good medical practice;
(3) All exception requests must represent cost-effective utilization of medical assistance program funds as determined by the agency or its designee;
(4) A request for an exception to rule must be submitted to the agency or its designee in writing within ninety days of the date of the written notification denying authorization for the noncovered service. For the agency or its designee to consider the exception to rule request:
(a) The client and/or the client's health care provider must submit sufficient client-specific information and documentation to the agency's medical director or designee which demonstrate the client's clinical condition is so different from the majority that there is no equally effective, less costly covered service or equipment that meets the client's need(s).
(b) The client's health care professional must certify that medical treatment or items of service which are covered under the client's medical assistance program and which, under accepted standards of medical practice, are indicated as appropriate for the treatment of the illness or condition, have been found to be:
(i) Medically ineffective in the treatment of the client's condition; or
(ii) Inappropriate for that specific client.
(5) Within fifteen business days of receiving the request, the agency or its designee sends written notification to the provider and the client:
(a) Approving the exception to rule request;
(b) Denying the exception to rule request; or
(c) Requesting additional information.
(i) The additional information must be received by the agency or its designee within thirty days of the date the information was requested.
(ii) The agency or its designee approves or denies the exception to rule request within five business days of receiving the additional information.
(iii) If the requested information is insufficient or not provided within thirty days, the agency or its designee denies the exception to rule request.
(6) The agency's medical director or designee evaluates and considers requests on a case-by-case basis. The agency's medical director has final authority or approve or deny a request for exception to rule.
(7) Clients do not have a right to a fair hearing on exception to rule decisions.
[Statutory Authority: RCW 41.05.021 and section 1927 of the Social Security Act. 12-18-062, § 182-501-0160, filed 8/31/12, effective 10/1/12. 11-14-075, recodified as § 182-501-0160, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-501-0160, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.04.050, 74.09.035. 00-03-035, § 388-501-0160, filed 1/12/00, effective 2/12/00. Statutory Authority: RCW 74.08.090. 94-10-065 (Order 3732), § 388-501-0160, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-030.]