This section addresses requests for limitation extensions regarding scope, amount, duration and/or frequency of a covered health care service. For the purposes of this section, health care services includes treatment, equipment, related supplies, and drugs. The department does not authorize or pay for any covered health care services exceeding identified limitations unless authorization is obtained prior to client receiving the service.
(1) No limitation extension of covered health care services will be authorized when prohibited by specific program rules.
(2) When a limitation extension is not prohibited by specific program rules, the client's provider may request a limitation extension.
(3) The department evaluates requests for limitation extensions as follows:
(a) For a fee-for-service client, the process described in WAC 388-501-0165
(b) For a managed care enrollee, the client's managed care organization (MCO) evaluates requests for limitation extensions according to the MCO's prior authorization process.
(c) Both the department and MCO consider the following in evaluating a request for a limitation extension:
(i) The level of improvement the client has shown to date related to the requested health care service and the reasonably calculated probability of continued improvement if the requested health care service is extended; and
(ii) The reasonably calculated probability the client's condition will worsen if the requested health care service is not extended.
[11-14-075, recodified as § 182-501-0169, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 09-23-112, § 388-501-0169, filed 11/18/09, effective 12/19/09; 06-24-036, § 388-501-0169, filed 11/30/06, effective 1/1/07.]