Chapter 182-502 WAC:

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Chapter 182-502 WAC

Last Update: 11/19/24

ADMINISTRATION OF MEDICAL PROGRAMS—PROVIDERS

WAC Sections

PROVIDER TYPES
HTML PDF	182-502-0002	Eligible provider types.
HTML PDF	182-502-0003	Noneligible provider types.
ENROLLMENT
HTML PDF	182-502-0005	Provider enrollment—Core provider agreement (CPA) or nonbilling provider agreement.
HTML PDF	182-502-0010	When the medicaid agency enrolls.
HTML PDF	182-502-0012	When the medicaid agency does not enroll.
HTML PDF	182-502-0014	Review and consideration of an applicant's history.
PROVIDER REQUIREMENTS
HTML PDF	182-502-0016	Continuing requirements.
HTML PDF	182-502-0017	Employee education about false claims recovery.
HTML PDF	182-502-0018	Change of ownership.
HTML PDF	182-502-0020	Health care record requirements.
HTML PDF	182-502-0022	Provider preventable conditions (PPCs)—Payment policy.
HTML PDF	182-502-0025	Electronic health records (EHR) incentive program.
TERMINATION OF PROVIDER
HTML PDF	182-502-0030	Termination of provider enrollment—For cause.
HTML PDF	182-502-0040	Termination of provider enrollment—For convenience.
INFORMAL DISPUTE RESOLUTION PROCESS
HTML PDF	182-502-0050	Provider dispute of an agency action.
REAPPLYING FOR PARTICIPATION
HTML PDF	182-502-0060	Reapplying for participation.
PAYMENT
HTML PDF	182-502-0100	General conditions of payment.
HTML PDF	182-502-0110	Conditions of payment and prior authorization requirements—Medicare coinsurance, copayments, and deductibles.
HTML PDF	182-502-0120	Payment for health care services provided outside the state of Washington.
INTEREST PENALTIES
HTML PDF	182-502-0130	Interest penalties—Providers.
TIME LIMITS FOR BILLING
HTML PDF	182-502-0150	Time limits for providers to bill the agency.
BILLING A CLIENT
HTML PDF	182-502-0160	Billing a client.
PROVIDER REPORTS
HTML PDF	182-502-0210	Statistical data-provider reports.
APPEAL—RATE REIMBURSEMENT
HTML PDF	182-502-0220	Administrative appeal contractor or provider rate reimbursement.
PROVIDER PAYMENT REVIEWS AND DISPUTE RIGHTS
HTML PDF	182-502-0230	Provider overpayment disputes—General.
HTML PDF	182-502-0260	Appeals and dispute resolution for providers with contracts other than core provider agreements.
HTML PDF	182-502-0270	Review of agency's provider dispute decision.

DISPOSITION OF SECTIONS FORMERLY CODIFIED IN THIS TITLE

182-502-0006

Enrollment for nonbilling individual providers. [Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. 455.432. WSR 15-10-003, § 182-502-0006, filed 4/22/15, effective 5/23/15. Statutory Authority: 42 C.F.R. 455.410, RCW 41.05.021. WSR 13-19-037, § 182-502-0006, filed 9/11/13, effective 10/12/13.] Repealed by WSR 24-23-009, filed 11/8/24, effective 12/9/24. Statutory Authority: RCW 41.05.021 and 41.05.160.

PDF182-502-0002

Eligible provider types.

The following health care professionals, health care entities, suppliers or contractors of service may request enrollment with the Washington state health care authority (medicaid agency) to provide covered health care services to eligible clients. For the purposes of this chapter, health care services include treatment, equipment, related supplies, and drugs.

(1) Professionals:

(a) Advanced registered nurse practitioners;

(b) Advanced social workers;

(d) Anesthesiologists;

(e) Applied behavior analysis (ABA) professionals, as provided in WAC 182-531A-0800:

(i) Licensed behavior analyst;

(ii) Licensed assistant behavior analyst; and

(iii) Certified behavior technician;

(f) Audiologists;

(g) Behavioral health support specialists (BHSS);

(h) Birth doulas;

(i) Chiropractors;

(j) Dentists;

(k) Dental health aide therapists, as provided in chapter 70.350 RCW;

(l) Dental hygienists;

(m) Denturists;

(n) Dietitians or nutritionists;

(o) Hearing aid fitters/dispensers;

(p) Home health aide credentialed with DOH as nursing assistant certified or nursing assistant registered;

(q) Independent clinical social workers;

(r) Independent clinical social worker associates;

(s) Licensed practical nurse;

(t) Marriage and family therapists;

(u) Mental health counselors;

(v) Mental health counselor associates;

(w) Mental health care providers;

(x) Midwives;

(y) Naturopathic physicians;

(z) Nurse anesthetist;

(aa) Ocularists;

(bb) Occupational therapists;

(cc) Ophthalmologists;

(dd) Opticians;

(ee) Optometrists;

(ff) Orthodontists;

(gg) Orthotist;

(hh) Osteopathic physicians;

(ii) Osteopathic physician assistants;

(jj) Peer counselors;

(kk) Podiatric physicians;

(ll) Pharmacists;

(mm) Physicians;

(nn) Physician assistants;

(oo) Physical therapists;

(pp) Prosthetist;

(qq) Psychiatrists;

(rr) Psychologists;

(ss) Radiologists;

(tt) Registered nurse;

(uu) Registered nurse delegators;

(vv) Registered nurse first assistants;

(ww) Respiratory therapists;

(xx) Speech/language pathologists; and

(yy) Substance use disorder professionals:

(i) Mental health providers; and

(ii) Peer counselors.

(2) Agencies, centers and facilities:

(a) Adult day health centers;

(b) Ambulance services (ground and air);

(d) Birthing centers (licensed by the department of health);

(e) Cardiac diagnostic centers;

(f) Case management agencies;

(g) Substance use disorder treatment facilities certified by the department of health (DOH);

(h) Withdrawal management treatment facilities certified by DOH;

(i) Community AIDS services alternative agencies;

(j) Community behavioral health support services provider facilities;

(k) Community mental health centers;

(l) Diagnostic centers;

(m) Early and periodic screening, diagnosis, and treatment (EPSDT) clinics;

(n) Family planning clinics;

(o) Federally qualified health centers (designated by the federal department of health and human services);

(p) Genetic counseling agencies;

(q) Health departments;

(r) Health maintenance organization (HMO)/managed care organization (MCO);

(s) HIV/AIDS case management;

(t) Home health agencies;

(u) Hospice agencies;

(v) Hospitals;

(w) Indian health service facilities/tribal 638 facilities;

(x) Tribal or urban Indian clinics;

(y) Inpatient psychiatric facilities;

(z) Intermediate care facilities for individuals with intellectual disabilities (ICF-IID);

(aa) Kidney centers;

(bb) Laboratories (CLIA certified);

(cc) Maternity support services agencies; maternity case managers; infant case management, first steps providers;

(dd) Neuromuscular and neurodevelopmental centers;

(ee) Nurse services/delegation;

(ff) Nursing facilities (approved by the DSHS aging and long-term support administration);

(gg) Pathology laboratories;

(hh) Pharmacies;

(ii) Private duty nursing agencies;

(jj) Radiology - Stand-alone clinics;

(kk) Rural health clinics (medicare-certified);

(ll) School districts and educational service districts; and

(mm) Sleep study centers.

(3) Suppliers of:

(a) Blood, blood products, and related services;

(b) Durable and nondurable medical equipment and supplies;

(d) Infusion therapy equipment and supplies;

(e) Prosthetics/orthotics;

(f) Hearing aids; and

(g) Respiratory care, equipment, and supplies.

(4) Contractors:

(a) Transportation brokers;

(b) Spoken language interpreter services agencies;

(d) Eyeglass and contact lens providers.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-23-096, s 182-502-0002, filed 11/19/24, effective 1/1/25; WSR 24-12-036, § 182-502-0002, filed 5/30/24, effective 7/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-502-0002, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021, 41.05.160, 71A.10.020(11), and chapter 18.205 RCW. WSR 23-04-071, § 182-502-0002, filed 1/30/23, effective 3/2/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-15-115, § 182-502-0002, filed 7/20/22, effective 8/20/22; WSR 22-07-105, § 182-502-0002, filed 3/23/22, effective 4/23/22. Statutory Authority: RCW 41.05.021, 41.05.160 and 2019 c 415 § 211(49). WSR 19-20-046, § 182-502-0002, filed 9/25/19, effective 10/26/19. Statutory Authority: RCW 41.05.021, 2013 c 178, and 2013 2nd sp.s. c 4. WSR 14-06-054, § 182-502-0002, filed 2/27/14, effective 3/30/14. WSR 11-14-075, recodified as § 182-502-0002, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0002, filed 5/9/11, effective 6/9/11.]

TERMINATION OF PROVIDER

PDF182-502-0003

Noneligible provider types.

The medicaid agency does not enroll licensed or unlicensed health care practitioners not specifically listed in WAC 182-502-0002, including, but not limited to:

(1) Acupuncturists;

(2) Sanipractors;

(3) Homeopaths;

(4) Herbalists;

(5) Massage therapists;

(6) Christian science practitioners, theological healers, and spiritual healers;

(7) Chemical dependency professional trainee (CDPT); and

(8) Mental health trainee (MHT).

[Statutory Authority: RCW 41.05.021, 2013 c 178, and 2013 2nd sp.s. c 4. WSR 14-06-054, § 182-502-0003, filed 2/27/14, effective 3/30/14. WSR 11-14-075, recodified as § 182-502-0003, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0003, filed 5/9/11, effective 6/9/11.]

INFORMAL DISPUTE RESOLUTION PROCESS

PDF182-502-0005

Provider enrollment—Core provider agreement (CPA) or nonbilling provider agreement.

(1) The agency only enrolls a health care professional, health care entity, supplier, or contractor of service through approval of an application for:

(a) A core provider agreement (CPA);

(b) A nonbilling provider agreement; or

(2) The agency may enter into a single case agreement or other forms of written agreements with a health care professional, health care entity, supplier, or contractor of service.

(3) Servicing providers must comply with the requirements for providers in the agreement under which they are enrolled and agency rules.

(4) Only a licensed health care professional whose scope of practice includes ordering, prescribing, or referring under their licensure may enroll as a nonbilling provider.

(5) An individual who is enrolled through a nonbilling provider agreement is exempt from the rules in WAC 182-502-0160 and may bill a client for health care services when:

(a) The provider is not enrolled with a managed care organization (MCO) that has a contract with the agency under WAC 182-538-067;

(b) The provider is not acting in their capacity as an ordering, prescribing, or referring provider of health care services for clients; and

(i) The provider is enrolled only for purposes of ordering, prescribing, or referring health care services for clients; and

(ii) The client may be billed for the health care services being provided.

(6) For services provided out-of-state, refer to WAC 182-501-0180, 182-501-0182, 182-501-0184, and 182-502-0120.

(7) Effective date of enrollment of a provider.

(a) Enrollment of a provider applicant is effective on the date the agency approves the provider application for enrollment or a date designated by the agency.

(b) A provider applicant may request an exception allowing an effective date earlier than the agency's approval of the provider application by submitting a written request to the agency.

(c) The request for an exception must specify the requested effective date and include an explanation justifying the earlier effective date.

(d) The agency will not authorize an effective date requested by the provider that is earlier than the effective date of any required license or certification.

(e) The agency may approve an exception as requested by the provider as follows for:

(i) Emergency services;

(ii) Agency-approved out-of-state services;

(iii) Medicaid provider entities that are subject to survey and certification by CMS or the state survey agency;

(iv) Retroactive client eligibility; or

(v) Other critical agency need.

(f) For federally qualified health centers (FQHCs), see WAC 182-548-1200. For rural health clinics (RHCs), see WAC 182-549-1200.

(g) Exceptions granted under this subsection do not supersede or otherwise change the agency's timely billing requirements under WAC 182-502-0150.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-23-009, s 182-502-0005, filed 11/8/24, effective 12/9/24; WSR 23-21-061, § 182-502-0005, filed 10/12/23, effective 11/12/23. Statutory Authority: 42 C.F.R. 455.410, RCW 41.05.021. WSR 13-19-037, § 182-502-0005, filed 9/11/13, effective 10/12/13. Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455 subpart E Provider Screening and Enrollment requirements. WSR 12-12-032, § 182-502-0005, filed 5/29/12, effective 7/1/12. WSR 11-14-075, recodified as § 182-502-0005, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0005, filed 5/9/11, effective 6/9/11.]

PAYMENT

PDF182-502-0010

When the medicaid agency enrolls.

(1) Nothing in this chapter obligates the medicaid agency to enroll any eligible health care professional, health care entity, supplier, or contractor of service who requests enrollment.

(2) To enroll as a provider (as defined in WAC 182-500-0085) with the agency, a health care professional, health care entity, supplier, or contractor of service rendering services in the state of Washington (persons or entities providing services out of Washington state see WAC 182-502-0120 and 182-501-0175) must, on the date of application:

(a) Be currently licensed, certified, accredited, or registered according to Washington state laws and rules, or, if exempt under federal law, according to the laws and rules of any other state;

(b) Be enrolled with medicare, when required in specific program rules;

(c) Have current professional liability coverage, individually or as a member of a group, to the extent the health care professional, health care entity, supplier or contractor is not covered by the Federal Tort Claims Act, including related rules and regulations;

(d) Have a current federal drug enforcement agency (DEA) certificate, if applicable to the profession's scope of practice;

(e) Meet the conditions in this chapter and other chapters regulating the specific type of health care practitioner;

(f) Sign, without modification, a core provider agreement (CPA) or nonbilling provider agreement, and a debarment form. Servicing providers are not required to sign as their enrollment is based upon being included under an organizational CPA or nonbilling provider agreement;

(g) Agree to accept the payment from the agency as payment in fullin accordance with 42 C.F.R. § 447.15 requiring acceptance of state payment as payment in full (see also WAC 182-502-0160 billing a client);

(h) Fully disclose ownership, employees who manage, and other control interests (e.g., member of a board of directors or office), as requested by the agency. Indian health services clinics are exempt from this requirement;

(i) Have screened employees and contractors with whom they do business prior to hiring or contracting to assure that employees and contractors are not excluded from receiving federal funds as required by 42 U.S.C. 1320a-7 and 42 U.S.C. 1320c-5;

(j) Pass the agency's screening process, including license verifications, database checks, site visits, and criminal background checks, including fingerprint-based criminal background checks as required by 42 C.F.R. 455.434 if considered high-risk under 42 C.F.R. 455.450.

(i) The agency uses the same screening level risk categories that apply under medicare.

(ii) For those provider types that are not recognized under medicare, the agency assesses the risk of fraud, waste, and abuse using similar criteria to those used in medicare; and

(k) Pay an application fee, if required by CMS under 42 C.F.R. 455.460.

(3) Servicing providers performing services for a client must be enrolled under the billing providers' CPA or a nonbilling provider agreement.

(4) Only a licensed health care professional whose scope of practice under their licensure includes ordering, prescribing, or referring may enroll as a nonbilling provider.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-23-009, s 182-502-0010, filed 11/8/24, effective 12/9/24. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. 455.432. WSR 15-10-003, § 182-502-0010, filed 4/22/15, effective 5/23/15. Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455. WSR 13-03-068, § 182-502-0010, filed 1/14/13, effective 2/14/13. Statutory Authority: RCW 41.05.021 and Affordable Care Act (ACA) - 76 Fed. Reg. 5862, 42 C.F.R. Parts 405, 424, 447, 455, 457, and 498. WSR 12-15-015, § 182-502-0010, filed 7/10/12, effective 9/1/12. WSR 11-14-075, recodified as § 182-502-0010, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0010, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.09.521. WSR 08-12-030, § 388-502-0010, filed 5/29/08, effective 7/1/08. Statutory Authority: RCW 74.08.090, 74.09.080, 74.09.120. WSR 03-14-106, § 388-502-0010, filed 6/30/03, effective 7/31/03. Statutory Authority: RCW 74.08.090, 74.09.500, and 74.09.530. WSR 01-07-076, § 388-502-0010, filed 3/20/01, effective 4/20/01; WSR 00-15-050, § 388-502-0010, filed 7/17/00, effective 8/17/00.]

PDF182-502-0012

When the medicaid agency does not enroll.

(1) The medicaid agency does not enroll a health care professional, health care entity, supplier, or contractor of service for reasons which include, but are not limited to, the following:

(a) The agency determines that:

(i) There is a quality of care issue with significant risk factors that may endanger client health, or safety, or both (see WAC 182-502-0030(1)); or

(ii) There are risk factors that affect the credibility, honesty, or veracity of the health care practitioner (see WAC 182-502-0030(1)).

(b) The health care professional, health care entity, supplier or contractor of service:

(i) Is excluded from participation in medicare, medicaid or any other federally funded health care program;

(ii) Has a current formal or informal pending disciplinary action, statement of charges, or the equivalent from any state or federal professional disciplinary body at the time of initial application;

(iii) Has a suspended, terminated, revoked, or surrendered professional license as defined under chapter 18.130 RCW;

(iv) Has a restricted, suspended, terminated, revoked, or surrendered professional license in any state;

(v) Is noncompliant with the department of health or other state health care agency's stipulation of informal disposition, agreed order, final order, or similar licensure restriction;

(vi) Is suspended or terminated by any agency within the state of Washington that arranges for the provision of health care;

(vii) Fails a background check, including a fingerprint-based criminal background check, performed by the agency. See WAC 182-502-0014 and 182-502-0016; or

(viii) Does not have sufficient liability insurance according to WAC 182-502-0016 for the scope of practice, to the extent the health care professional, health care entity, supplier or contractor of service is not covered by the Federal Tort Claims Act, including related rules and regulations.

(c) A site visit under 42 C.F.R. 455.432 reveals that the provider has failed to comply with a state or federal requirement.

(2) If the agency denies an enrollment application under this section, the applicant may reapply.

(3) Under 42 C.F.R. 455.470, the agency:

(a) Will impose a temporary moratorium on enrollment when directed by CMS; or

(b) May initiate and impose a temporary moratorium on enrollment when approved by CMS.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-23-009, s 182-502-0012, filed 11/8/24, effective 12/9/24; WSR 19-21-067, § 182-502-0012, filed 10/11/19, effective 11/11/19. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. 455.432. WSR 15-10-003, § 182-502-0012, filed 4/22/15, effective 5/23/15. Statutory Authority: RCW 41.05.021. WSR 13-17-047, § 182-502-0012, filed 8/13/13, effective 10/1/13. Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455. WSR 13-03-068, § 182-502-0012, filed 1/14/13, effective 2/14/13. WSR 11-14-075, recodified as § 182-502-0012, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0012, filed 5/9/11, effective 6/9/11.]

PDF182-502-0014

Review and consideration of an applicant's history.

(1) The medicaid agency may consider enrolling a health care professional, health care entity, supplier or contractor of service for reasons which include, but are not limited to, the following:

(a) The agency determines that:

(i) There is not a quality of care issue with significant risk factors that endanger client health or safety, or both;

(ii) There are not risk factors that affect the credibility, honesty, or veracity of the applicant; and

(iii) The applicant is not likely to repeat the violation that led to a restriction or sanction.

(b) The health care professional, health care entity, supplier or contractor of service has:

(i) Been excluded from participation in medicare, medicaid, or any other federally funded health care program but is not currently excluded; or

(ii) A history of probation, suspension, termination, revocation, or a surrendered professional license, certification, accreditation, or registration as defined under chapter 18.130 RCW but currently has an active license, certification, accreditation, or registration; or

(iii) A restricted or limited professional license, certification, accreditation, or registration as defined under RCW 18.130.160; or

(iv) A history of denial, limitation, suspension or termination of participation or privileges by any health care institution, plan, facility, clinic, or state agency for quality of care issues or inappropriate billing practices and the quality of care issue or inappropriate billing practices have been corrected to the agency's satisfaction.

(2) The agency conducts a screening process as specified in WAC 182-502-0010 (2)(j) on any applicant applying for a core provider agreement (CPA) or enrolling to provide services to eligible clients.

(3) The agency's response to a review of a request for enrollment is based on the information available to the agency at the time of application.

[Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455. WSR 13-03-068, § 182-502-0014, filed 1/14/13, effective 2/14/13. WSR 11-14-075, recodified as § 182-502-0014, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0014, filed 5/9/11, effective 6/9/11.]

BILLING A CLIENT

PDF182-502-0016

Continuing requirements.

(1) To continue to provide services for eligible clients and be paid for those services, a provider must:

(a) Provide all services without discriminating on the grounds of race, creed, color, age, sex, sexual orientation, religion, national origin, marital status, the presence of any sensory, mental or physical handicap, or the use of a trained dog guide or service animal by a person with a disability;

(b) Provide all services according to federal and state laws and rules, medicaid agency billing instructions, provider alerts issued by the agency, and other written directives from the agency;

(c) Inform the agency of any changes to the provider's application or contract including, but not limited to, changes in:

(i) Ownership (see WAC 182-502-0018);

(ii) Address or telephone number;

(iii) The professional practicing under the billing provider number; or

(iv) Business name.

(d) Retain a current professional state license, registration, certification or applicable business license for the service being provided, and update the agency of all changes;

(e) Inform the agency in writing within seven calendar days of changes applicable to the provider's clinical privileges;

(f) Inform the agency in writing within seven business days of receiving any informal or formal disciplinary order, disciplinary decision, disciplinary action or other action(s) including, but not limited to, restrictions, limitations, conditions and suspensions resulting from the practitioner's acts, omissions, or conduct against the provider's license, registration, or certification in any state;

(g) Screen employees and contractors with whom they do business prior to hiring or contracting, and on a monthly ongoing basis thereafter, to assure that employees and contractors are not excluded from receiving federal funds as required by 42 U.S.C. 1320a-7 and 42 U.S.C. 1320c-5;

(h) Report immediately to the agency any information discovered regarding an employee's or contractor's exclusion from receiving federal funds in accordance with 42 U.S.C. 1320a-7 and 42 U.S.C. 1320c-5. See WAC 182-502-0010 (2)(j) for information on the agency's screening process;

(i) Pass any portion of the agency's screening process as specified in WAC 182-502-0010 (2)(j) when the agency requires such information to reassess a provider;

(j) Maintain professional and general liability coverage to the extent the provider is not covered:

(i) Under agency, center, or facility professional and general liability coverage; or

(ii) By the Federal Tort Claims Act, including related rules and regulations.

(k) Not surrender, voluntarily or involuntarily, the provider's professional state license, registration, or certification in any state while under investigation by that state or due to findings by that state resulting from the practitioner's acts, omissions, or conduct;

(l) Furnish documentation or other assurances as determined by the agency in cases where a provider has an alcohol or chemical dependency problem, to adequately safeguard the health and safety of medical assistance clients that the provider:

(i) Is complying with all conditions, limitations, or restrictions to the provider's practice both public and private; and

(ii) Is receiving treatment adequate to ensure that the dependency problem will not affect the quality of the provider's practice.

(m) Submit to a revalidation process at least every five years. This process includes, but is not limited to:

(i) Updating provider information including, but not limited to, disclosures;

(ii) Submitting forms as required by the agency including, but not limited to, a new core provider agreement; and

(iii) Passing the agency's screening process as specified in WAC 182-502-0010 (2)(j).

(n) Comply with the employee education requirements regarding the federal and the state false claims recovery laws, the rights and protections afforded to whistleblowers, and related provisions in Section 1902 of the Social Security Act (42 U.S.C. 1396a(68)) and chapter 74.66 RCW when applicable. See WAC 182-502-0017 for information regarding the agency's requirements for employee education about false claims recovery.

(2) A provider may contact the agency with questions regarding its programs. However, the agency's response is based solely on the information provided to the agency's representative at the time of inquiry, and in no way exempts a provider from following the laws and rules that govern the agency's programs.

(3) The agency may refer the provider to the appropriate state health professions quality assurance commission.

(4) In addition to the requirements in subsections (1), (2), and (3) of this section, to continue to provide services for eligible clients and be paid for those services, residential treatment facilities that provide substance use disorder (SUD) services (also see chapter 246-337 WAC) must:

(a) Not deny entry or acceptance of clients into the facility solely because the client is prescribed medication to treat SUD;

(b) Facilitate access to medications specific to the client's diagnosed clinical needs, including medications used to treat SUD;

(c) Make any decisions regarding adjustments to medications used to treat SUD after individual assessment by a prescribing provider;

(d) Coordinate care upon discharge for the client to continue without interruption the medications specific to the client's diagnosed clinical needs, including medications used to treat SUD. See RCW 71.24.585.

[Statutory Authority: RCW 41.05.021, 41.05.160, 71.24.035, 71.24.520, 71.24.585 and 42 U.S.C. 1315 (Sec. 1115). WSR 21-10-081, § 182-502-0016, filed 5/3/21, effective 6/3/21. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. Sec. 1396 (a)(68). WSR 19-20-060, § 182-502-0016, filed 9/26/19, effective 10/27/19. Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. 455.432. WSR 15-10-003, § 182-502-0016, filed 4/22/15, effective 5/23/15. Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455. WSR 13-03-068, § 182-502-0016, filed 1/14/13, effective 2/14/13. WSR 11-14-075, recodified as § 182-502-0016, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0016, filed 5/9/11, effective 6/9/11.]

PDF182-502-0017

Employee education about false claims recovery.

(1) The medicaid agency (agency) requires any entity (including providers) that makes or receives medical assistance payments from the agency or the agency designee of at least $5,000,000 annually under the state plan to meet the requirements of Section 1902 (a)(68) of the Social Security Act in order to receive payments.

(2) Entity policies and procedures. Entities must adopt and disseminate policies and procedures for their employees, contractors, and agents regarding federal and state false claims and whistleblower protection laws.

(a) Written policies and procedures may be in paper or electronic form, but must be readily available to all employees, contractors, and agents.

(b) If the entity has an employee handbook, it must include a specific discussion of the laws described in written policies regarding the rights of employees to be protected as whistleblowers, and a specific discussion of the entity's policies and procedures for detecting and preventing fraud, waste, and abuse.

(3) Entity. An "entity" may include, but is not limited to, individual providers, a governmental agency, organization, unit, corporation, partnership, or other business arrangement irrespective of the form of business structure by which it exists or whether for-profit or not-for-profit.

(a) An organization may have multiple subsidiaries, locations, federal employer identification numbers (FEIN), or provider numbers and still be combined for the purposes of meeting the definition of an entity.

(b) Whether subsidiaries would be aggregated or viewed as separate entities depends on the corporate structure and assessment of the largest separate organizational unit that furnishes medicaid health care items or services.

(c) The agency and its designee administering the medicaid program, or any agent performing an administrative function, are not considered entities.

(4) Payments received. For any entity that receives medical assistance payments under the state plan of at least $5,000,000 annually, the total amount includes:

(a) All payments received by an entity who furnishes items or services at one or more location(s);

(b) All payments received by an entity who furnishes items or services under one or more contractual or other payment arrangement(s);

(c) Only the amounts received from the agency or the agency designee. The amounts paid by a managed care organization (MCO) to the entity are only counted against the MCO, not the entity, when calculating the $5,000,000 threshold; and

(d) Only payments received from Washington state. Payments from multiple states are not aggregated to reach the $5,000,000 annual threshold.

(5) Annual monitoring. At the conclusion of each federal fiscal year, the agency identifies who qualifies as an entity subject to the requirements in Section 1902 (a)(68) of the Social Security Act.

(a) If the agency determines that an entity is subject to and must comply with Section 1902 (a)(68) of the act:

(i) The agency provides written notice to the entity that it must comply;

(ii) The entity must submit an attestation to the agency under penalty of perjury to verify the entity has adopted and disseminated compliant, written policies as required; and

(iii) The agency may request copies of the written policies and proof of dissemination to verify compliance with the requirements.

(b) If the agency does not receive the required documentation by the due date, the agency sends a warning to the entity to become compliant by a specified deadline.

(c) If the entity remains noncompliant after the deadline, the agency ceases medical assistance payments until the entity is compliant.

[Statutory Authority: RCW 41.05.021, 41.05.160 and 42 U.S.C. Sec. 1396 (a)(68). WSR 19-20-060, § 182-502-0017, filed 9/26/19, effective 10/27/19.]

PDF182-502-0018

Change of ownership.

(1) A provider must notify the medicaid agency in writing within seven calendar days of ownership or control changes of any kind. An entity is considered to have an ownership or control interest in another entity if it has direct or indirect ownership of five percent or more, or is a managing employee (e.g., a general manager, business manager, administrator, or director) who exercises operational or managerial control over the entity or who directly or indirectly conducts day-to-day operations of the entity. The agency determines whether a new core provider agreement (CPA) must be completed for the new entity.

(2) When a provider obtains a new federal tax identification (ID) following a change of ownership, the agency terminates the provider's CPA as of the date of the change in federal tax ID. The provider may reapply for a new CPA.

(3) All new ownership enrollments are subject to the requirements in WAC 182-502-0010. In addition to those requirements, the applicant must:

(a) Complete a change of ownership form;

(b) Provide the agency with a copy of the contract of sale identifying previous and current owners; and

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0018, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0018, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0018, filed 5/9/11, effective 6/9/11.]

PDF182-502-0020

Health care record requirements.

This section applies to providers, as defined under WAC 182-500-0085 and under WAC 182-538-050. Providers must:

(1) Maintain documentation in the client's medical or health care records to verify the level, type, and extent of services provided to each client to fully justify the services and billing, including, but not limited to:

(a) Client's name and date of birth;

(b) Dates of services;

(d) Chief complaint or reason for each visit;

(e) Pertinent past and present medical history;

(f) Pertinent findings on examination at each visit;

(g) Medication(s) or treatment prescribed and/or administered;

(h) Name and title of individual prescribing or administering medication(s);

(i) Equipment and/or supplies prescribed or provided;

(j) Name and title of individual prescribing or providing equipment and/or supplies;

(k) Detailed description of treatment provided;

(l) Subjective and objective findings;

(m) Clinical assessment and diagnosis;

(n) Recommendations for additional treatments, procedures, or consultations;

(o) Radiographs (X-rays), diagnostic tests and results;

(p) Plan of treatment and/or care, and outcome;

(q) Specific claims and payments received for services;

(r) Correspondence pertaining to client dismissal or termination of health care practitioner/patient relationship;

(s) Advance directives, when required under WAC 182-501-0125;

(t) Patient treatment agreements (examples: Opioid agreement, medication and treatment compliance agreements); and

(u) Informed consent documentation.

(2) Keep legible, accurate, and complete charts and records;

(3) Meet any additional record requirements of the department of health (DOH);

(4) Assure charts are authenticated by the person who gave the order, provided the care, or performed the observation, examination, assessment, treatment or other service to which the entry pertains;

(5) Make charts and records available to the medicaid agency, its contractors or designees, and the United States Department of Health and Human Services (DHHS) upon request, for six years from the date of service or longer if required specifically by federal or state law or regulation. The agency does not separately reimburse for copying of health care records, reports, client charts and/or radiographs, and related copying expenses; and

(6) Permit the agency, DHHS, and its agents or designated contractors, access to its physical facilities and its records to enable the agency and DHHS to conduct audits, inspections, or reviews without prior announcement.

[Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455. WSR 13-03-068, § 182-502-0020, filed 1/14/13, effective 2/14/13. WSR 11-14-075, recodified as § 182-502-0020, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0020, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 74.09.530. WSR 01-07-076, § 388-502-0020, filed 3/20/01, effective 4/20/01; WSR 00-15-050, § 388-502-0020, filed 7/17/00, effective 8/17/00.]

APPEAL—RATE REIMBURSEMENT

PDF182-502-0022

Provider preventable conditions (PPCs)—Payment policy.

(1) This section establishes the agency's payment policy for services provided to medicaid clients on a fee-for-service basis or to a client enrolled in a managed care organization (defined in WAC 182-538-050) by health care professionals and inpatient hospitals that result in provider preventable conditions (PPCs).

(2) The rules in this section apply to:

(a) All health care professionals who bill the agency directly; and

(b) Inpatient hospitals.

(3) Definitions. The following definitions and those found in chapter 182-500 WAC apply to this section:

(a) Agency - See WAC 182-500-0010.

(b) Health care-acquired conditions (HCAC) - A condition occurring in any inpatient hospital setting (identified as a hospital acquired condition by medicare other than deep vein thrombosis/pulmonary embolism as related to a total knee replacement or hip replacement surgery in pediatric and obstetric patients.) Medicare's list of hospital acquired conditions is also available at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html.

(c) Other provider preventable conditions (OPPC) - The list of serious reportable events in health care as identified by the department of health in WAC 246-302-030 and published by the National Quality Forum.

(d) Present on admission (POA) indicator - A status code the hospital uses on an inpatient claim that indicates if a condition was present at the time the order for inpatient admission occurs.

(e) Provider preventable condition (PPC) - An umbrella term for hospital and nonhospital acquired conditions identified by the agency for nonpayment to ensure the high quality of medicaid services. PPCs include two distinct categories: Health care-acquired conditions (HCACs) and other provider-preventable conditions (OPPCs).

(4) Health care-acquired condition (HCAC) - The agency will deny or recover payment to health care professionals and inpatient hospitals for care related only to the treatment of the consequences of a HCAC.

(a) HCAC conditions include:

(i) Foreign object retained after surgery;

(ii) Air embolism;

(iii) Blood incompatibility;

(iv) Stage III and IV pressure ulcers;

(v) Falls and trauma:

(A) Fractures;

(B) Dislocations;

(D) Crushing injuries;

(E) Burns;

(F) Other injuries.

(vi) Manifestations of poor glycemic control:

(A) Diabetic ketoacidosis;

(B) Nonketotic hyperosmolar coma;

(D) Secondary diabetes with ketoacidosis;

(E) Secondary diabetes with hyperosmolarity.

(vii) Catheter-associated urinary tract infection (UTI);

(viii) Vascular catheter-associated infection;

(ix) Surgical site infection, mediastinitis, following coronary artery bypass graft (CABG);

(x) Surgical site infection following bariatric surgery for obesity:

(A) Laparoscopic gastric bypass;

(B) Gastroenterostomy; or

(xi) Surgical site infection following certain orthopedic procedures:

(A) Spine;

(B) Neck;

(D) Elbow.

(xii) Surgical site infection following cardiac implantable electronic device (CIED).

(xiii) Deep vein thrombosis/pulmonary embolism (DVT/PE) following certain orthopedic procedures:

(A) Total knee replacement; or

(B) Hip replacement.

(xiv) Latrogenic pneumothorax with venous catheterization.

(b) Hospitals must include the present on admission (POA) indicator when submitting inpatient claims for payment. The POA indicator is to be used according to the official coding guidelines for coding and reporting and the CMS guidelines. The POA indicator may prompt a review, by the agency or the agency's designee, of inpatient hospital claims with an HCAC diagnosis code when appropriate according to the CMS guidelines. The agency will identify professional claims using the information provided on the hospital claims.

(c) HCACs are based on current medicare inpatient prospective payment system rules with the inclusion of POA indicators. Health care professionals and inpatient hospitals must report HCACs on claims submitted to the agency for consideration of payment.

(5) Other provider preventable condition (OPPC) - The agency will deny or recoup payment to health care professionals and inpatient hospitals for care related only to the treatment of consequences of an OPPC when the condition:

(a) Could have reasonably been prevented through the application of nationally recognized evidence based guidelines;

(b) Is within the control of the hospital;

(d) Has a negative consequence for the beneficiary;

(e) Is auditable; and

(f) Is included on the list of serious reportable events in health care as identified by the department of health in WAC 246-302-030 effective on the date the incident occurred. The list of serious reportable events in health care, as of the publishing of this rule, includes:

(i) Surgical or invasive procedure events:

(A) Surgical or other invasive procedure performed on the wrong site;

(B) Surgical or other invasive procedure performed on the wrong patient;

(D) Unintended retention of a foreign object in a patient after surgery or other invasive procedure;

(E) Intraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patient.

(ii) Product or device events:

(A) Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the hospital;

(B) Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used or functions other than as intended;

(C) Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a hospital.

(iii) Patient protection events:

(A) Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person;

(B) Patient death or serious injury associated with patient elopement;

(C) Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a hospital.

(iv) Care management events:

(A) Patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration);

(B) Patient death or serious injury associated with unsafe administration of blood products;

(C) Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a hospital;

(D) Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy;

(E) Patient death or serious injury associated with a fall while being cared for in a hospital;

(F) Any stage 3, stage 4, or unstageable pressure ulcers acquired after admission/presentation to a hospital (not present on admission);

(G) Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen;

(H) Patient death or serious injury resulting from failure to follow-up or communicate laboratory, pathology, or radiology test results.

(v) Environmental events:

(A) Patient death or serious injury associated with an electric shock in the course of a patient care process in a hospital;

(B) Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances;

(C) Patient death or serious injury associated with a burn incurred from any source in the course of a patient care process in a hospital;

(D) Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a hospital.

(vi) Radiologic events: Death or serious injury of a patient associated with the introduction of a metallic object into the magnetic resonance imaging (MRI) area.

(vii) Potential criminal event:

(A) Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider;

(B) Abduction of a patient of any age;

(D) Death or serious injury of a patient resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a health care setting.

(6) Reporting PPCs.

(a) The agency requires inpatient hospitals to report PPCs (as appropriate according to (d) and (e) of this subsection) to the agency by using designated present on admission (POA) indicator codes and appropriate HCPCs modifiers that are associated:

(i) With claims for medical assistance payment; or

(ii) With courses of treatment furnished to clients for which medical assistance payment would otherwise be available.

(b) Health care professionals and inpatient hospitals must report PPCs associated with medicaid clients to the agency even if the provider does not intend to bill the agency.

(i) A condition was present at the time of inpatient hospital admission or at the time the client was first seen by the health care professional or hospital; or

(ii) A condition occurred during admission or encounter with a health care professional either inpatient or outpatient.

(d) Hospitals must notify the agency of an OPPC associated with an established medicaid client within 45 calendar days of the confirmed OPPC in accordance with RCW 70.56.020. If the client's medicaid eligibility status is not known or established at the time the OPPC is confirmed, the agency allows hospitals 30 days to notify the agency once the client's eligibility is established or known.

(i) Notification must be in writing, addressed to the agency's office of program integrity, and include the OPPC, date of service, client identifier, and the claim number if the facility submits a claim to the agency.

(ii) Hospitals must complete the appropriate portion of the HCA 12-200 form to notify the agency of the OPPC. Agency forms are available for download at https://www.hca.wa.gov/billers-providers-partners/forms-and-publications.

(e) Health care professionals or designees responsible for or may have been associated with the occurrence of a PPC involving a medicaid client must notify the agency within 45 calendar days of the confirmed PPC in accordance with chapter 70.56 RCW. Notifications must be in writing, addressed to the agency's chief medical officer, and include the PPC, date of service, and client identifier. Providers must complete the appropriate portion of the HCA 12-200 form to notify the agency of the PPC. Agency forms are available for download at www.hca.wa.gov/billers-providers-partners/forms-and-publications.

(f) Failure to report, code, bill or claim PPCs according to the requirements in this section will result in loss or denial of payments.

(7) Identifying PPCs. The agency may identify PPCs as follows:

(a) Through the department of health (DOH); or

(b) Through the agency's program integrity efforts, including:

(i) The agency's claims payment system;

(ii) Retrospective hospital utilization review process (see WAC 182-550-1700);

(iii) The agency's provider payment review process (see WAC 182-502-0230);

(iv) The agency's provider audit process (see chapter 182-502A WAC); and

(v) A provider or client complaint.

(8) Payment adjustment for PPCs. The agency or its designee conducts a review of the PPC prior to reducing or denying payment.

(a) The agency does not reduce, recoup, or deny payment to a provider for a PPC when the condition:

(i) Existed prior to the initiation of treatment for that client by that provider. Documentation must be kept in the client's clinical record to clearly support that the PPC existed prior to initiation of treatment; or

(ii) Is directly attributable to a comorbid condition(s).

(b) The agency reduces payment to a provider when the following applies:

(i) The identified PPC would otherwise result in an increase in payment; and

(ii) The portion of the professional services payment directly related to the PPC, or treatment of the PPC, can be reasonably isolated for nonpayment.

(c) The agency does not make additional payments for services on claims for covered health care services that are attributable to HCACs and/or are coded with POA indicator codes "N" or "U."

(d) Medicare crossover claims. The agency applies the following rules for these claims:

(i) If medicare denies payment for a claim at a higher rate for the increased costs of care under its PPC policies:

(A) The agency limits payment to the maximum allowed by medicare;

(B) The agency does not pay for care considered nonallowable by medicare; and

(ii) If medicare denies payment for a claim under its national coverage determination agency from Section 1862 (a)(1)(A) of the Social Security Act (42 U.S.C. 1395) for an adverse health event:

(A) The agency does not pay the claim, any medicare deductible or any coinsurance related to the inpatient hospital and health care professional services; and

(B) The client cannot be held liable for payment.

(9) The agency will calculate its reduction, denial or recoupment of payment based on the facts of each OPPC or HCAC. Any overpayment applies only to the health care professional or hospital where the OPPC or HCAC occurred and does not apply to care provided by other health care professionals and inpatient hospitals, should the client subsequently be transferred or admitted to another hospital for needed care.

(10) Medicaid clients are not liable for payment of an item or service related to an OPPC or HCAC or the treatment of consequences of an OPPC or HCAC that would have been otherwise payable by the agency, and must not be billed for any item or service related to a PPC.

(11) Provider dispute process for PPCs.

(a) A health care professional or inpatient hospital may dispute the agency's reduction, denial or recoupment of payment related to a PPC as described in chapter 182-502A WAC.

(b) The disputing health care professional or inpatient hospital must provide the agency with the following information:

(i) The health care professional or inpatient hospital's assessment of the PPC; and

(ii) A complete copy of the client's medical record and all associated billing records, to include itemized statement or explanation of charges.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-04-033, § 182-502-0022, filed 1/25/23, effective 2/25/23; WSR 19-08-037, § 182-502-0022, filed 3/28/19, effective 4/28/19. Statutory Authority: RCW 41.05.021. WSR 13-19-038, § 182-502-0022, filed 9/11/13, effective 10/12/13. Statutory Authority: 42 C.F.R. § 447.26. WSR 13-11-051, § 182-502-0022, filed 5/14/13, effective 7/1/13.]

PDF182-502-0025

Electronic health records (EHR) incentive program.

The purpose of this section is to establish the medicaid electronic health records (EHR) incentive program under the American Recovery and Reinvestment Act of 2009 (ARRA). The medicaid EHR incentive program promotes the adoption and meaningful use of certified EHR technology by offering financial incentives to eligible professionals and hospitals. This program is administered by the medicaid agency.

(1) The agency provides incentive payments to eligible providers and hospitals that adopt and meaningfully use certified EHR technology under 42 C.F.R. Parts 412, 413, 422, and any other federal regulations that apply.

(2) Providers and hospitals eligible to participate in EHR incentive program are identified in 42 C.F.R. Part 495.304 and other applicable rules.

(3) As authorized by 42 C.F.R. Parts 412, 413, 422, chapters 43.20B and 74.09 RCW, and any other federal or state rules that apply, the agency monitors and reviews all providers and hospitals participating in the EHR incentive program. By the same authority, the agency reviews all practices, documentation, and data related to EHR technology to determine whether professionals and hospitals participating in the EHR incentive program are eligible and complying with state and federal rules and regulations.

(4) The agency may determine that a participating professional or hospital has not met the eligibility or performance requirements to receive an EHR incentive payment, or should receive an incentive payment in an amount less than the amount anticipated by the provider or hospital. Areas of possible dispute in the EHR incentive program include, at a minimum, any of the following:

(a) Patient volume thresholds and calculations, as outlined in 42 C.F.R. Parts 495.304 and 495.306.

(b) Eligibility criteria and payment limitations, as outlined in 42 C.F.R. Parts 495.10, 495.304, 495.306, and 495.310.

(i) Attestations that certified EHR technology has been adopted, implemented, or upgraded; and

(ii) Demonstrations of meaningful use, as outlined in 42 C.F.R. Parts 495.6, 495.8, 495.306, 495.310, and in any future published federal regulations and requirements, as applicable.

(d) The payment process and incentive payment amounts, as outlined in 42 C.F.R. Parts 495.310, 495.312, and 495.314.

(e) Additional issues regarding EHR incentive program eligibility, participation, documentation, and compliance as outlined in 42 C.F.R. Parts 412, 413, 422, and in any future published federal regulations and requirements, as applicable.

(5) All matters of dispute are subject to the Administrative Procedure Act (APA) appeal process under chapter 34.05 RCW. A provider who disagrees with an agency action under this section may request a hearing. The hearing request must:

(a) Be in writing;

(b) Be received by the agency, at the address identified in the notice of action, within twenty-eight days of the date of the notice of action by certified mail (return receipt); and

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0025, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0025, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-13-053, § 388-502-0025, filed 6/10/11, effective 7/11/11.]

PDF182-502-0030

Termination of provider enrollment—For cause.

(1) The medicaid agency may immediately terminate a provider's enrollment for any one or more of the following reasons, each of which constitutes cause:

(a) Provider exhibits significant risk factors that endanger client health or safety. These factors include, but are not limited to:

(i) Moral turpitude;

(ii) Sexual misconduct according to chapter 246-16 WAC or in profession specific rules of the department of health (DOH);

(iii) A statement of allegations or statement of charges by DOH or equivalent from other state licensing boards;

(iv) Restrictions or limitations placed by any state licensing, credentialing, or certification agency on the provider's current credentials or practice;

(v) Limitations, restrictions, or loss of hospital privileges or participation in any health care plan or failure to disclose the reasons to the agency;

(vi) Negligence, incompetence, inadequate or inappropriate treatment, or lack of appropriate follow-up treatment;

(vii) Patient drug mismanagement, failure to identify substance use disorder, or failure to refer the patient for substance use disorder treatment once identified;

(viii) Use of health care providers or health care staff who are unlicensed to practice or who provide health care services that are outside their recognized scope of practice or the standard of practice in the state of Washington;

(ix) Failure of the health care provider to comply with the requirements of WAC 182-502-0016;

(x) Failure of the health care provider with a substance use disorder(s) to furnish documentation or other assurances as determined by the agency to adequately safeguard the health and safety of Washington apple health clients that the provider:

(A) Is complying with all conditions, limitations, or restrictions to the provider's practice both public and private; and

(B) Is receiving treatment adequate to ensure that the disorder will not affect the quality of the provider's practice.

(xi) Infection control deficiencies;

(xii) Failure to maintain adequate professional malpractice coverage;

(xiii) Medical malpractice claims or professional liability claims that constitute a pattern of questionable or inadequate treatment, or contain any gross or flagrant incident of malpractice; or

(xiv) Any other act that the agency determines is contrary to the health and safety of its clients.

(b) Provider exhibits significant risk factors that affect the provider's credibility or honesty. These factors include, but are not limited to:

(i) Failure to meet the requirements in WAC 182-502-0010 and 182-502-0020;

(ii) Dishonesty or other unprofessional conduct;

(iii) Civil or criminal findings of fraudulent or abusive billing practices through an investigation or other review (e.g., audit or record review);

(iv) Exclusion from participation in medicare, medicaid, or any other federally funded health care program;

(v) Any conviction, no contest plea, or guilty plea relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct;

(vi) Any conviction, no contest plea, or guilty plea of a criminal offense;

(vii) Failure to comply with a DOH request for information or an ongoing DOH investigation;

(viii) Noncompliance with a DOH or other state health care agency's stipulation to disposition, agreed order, final order, or other similar licensure restriction;

(ix) Misrepresentation or failure to disclose information to the agency during or after enrollment including on the application for a core provider agreement (CPA), a nonbilling provider agreement, or servicing providers enrolled under a core provider agreement;

(x) Failure to comply with an agency request for information;

(xi) Failure to submit adequate documentation to the agency or failure to retain adequate documentation as required by the agency;

(xii) Failure to cooperate with an agency investigation, audit, or review;

(xiii) Providing health care services that are outside the provider's recognized scope of practice or the standard of practice in the state of Washington;

(xiv) Unnecessary medical, dental, or other health care procedures;

(xv) Discriminating in the furnishing of health care services, supplies, or equipment as prohibited by 42 U.S.C. § 2000d; and

(xvi) Any other dishonest or discreditable act that the agency determines is contrary to the interest of the agency or its clients.

(2) If a provider's enrollment is terminated for cause, the agency pays only for authorized services provided up to the date of termination of enrollment if other program requirements are met including, but not limited to, the requirements in WAC 182-502-0016.

(3) When the agency terminates enrollment of a servicing provider who is also a full or partial owner of an enrolled group practice, the agency terminates the enrolled group practice and all enrolled servicing providers who are not linked to another enrolled group practice contracted with the agency. The remaining practitioners in the group practice may reapply for participation with the agency subject to WAC 182-502-0010.

(4) Effective date. The effective date of the termination of a provider's enrollment is the date stated in the notice. The filing of an appeal as provided in subsection (5) of this section does not stay the effective date of termination.

(5) Administrative hearing.

(a) The provider may appeal the agency decision to terminate the provider's enrollment for cause by submitting a written request to the address contained in the decision notice within 28 calendar days of the date on the notice and in a manner that provides proof of receipt by the agency. The agency does not allow good cause exception related to this subsection.

(b) If the agency receives a timely appeal, the presiding officer will schedule a prehearing conference in accordance with WAC 182-526-0195.

(c) The administrative hearing process is governed by the Administrative Procedure Act, chapter 34.05 RCW, and chapter 182-526 WAC.

(d) Burden of proof.

(i) The provider has the burden of proof.

(ii) The standard of proof in a provider termination hearing is "clear and convincing evidence" meaning the evidence is highly and substantially more likely to be true than untrue. This is a higher standard of proof than proof by a preponderance of the evidence, but it does not require proof beyond a reasonable doubt.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-23-009, s 182-502-0030, filed 11/8/24, effective 12/9/24; WSR 23-21-061, § 182-502-0030, filed 10/12/23, effective 11/12/23; WSR 15-14-039, § 182-502-0030, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0030, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0030, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.530. WSR 00-15-050, § 388-502-0030, filed 7/17/00, effective 8/17/00.]

PDF182-502-0040

Termination of provider enrollment—For convenience.

(1) Either the medicaid agency or the provider may terminate the provider's enrollment with the agency for convenience with 28 calendar days written notice in a manner which provides proof of receipt or proof of valid attempt to deliver the notice.

(2) Termination of enrollment for convenience is the agency's final decision.

(3) If a provider is terminated for convenience, the agency pays for authorized services provided up to the date of termination only.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-23-009, s 182-502-0040, filed 11/8/24, effective 12/9/24; WSR 19-21-067, § 182-502-0040, filed 10/11/19, effective 11/11/19. WSR 11-14-075, recodified as § 182-502-0040, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0040, filed 5/9/11, effective 6/9/11.]

PDF182-502-0050

Provider dispute of an agency action.

The process described in this section applies only when agency rules allow a provider to dispute an agency decision under this section.

(1) In order for the agency to review a decision previously made by the agency, a provider must submit the request to review the decision:

(a) Within 28 calendar days of the date on the agency's decision notice;

(b) To the address listed in the decision notice; and

(2) A provider's dispute request must:

(a) Be in writing;

(b) Specify the agency decision that the provider is disputing;

(d) Include documentation to support the provider's position.

(3) The agency may request additional information or documentation. The provider must submit the additional information or documentation to the agency within 28 calendar days of the date on the agency's request.

(4) The agency closes the dispute without issuing a decision and with no right to further review under subsection (6) of this section when the provider:

(a) Fails to comply with any requirement of subsections (2), (3), and (4) of this section;

(b) Fails to cooperate with, or unduly delays, the dispute process; or

(5) The agency will send the provider a written notice of dispute closure or written dispute decision.

(6) The provider may request the director of the health care authority or designee to review the written dispute decision according to the process in WAC 182-502-0270.

(7) This section does not apply to disputes regarding overpayment. For disputes regarding overpayment, see WAC 182-502-0230 and chapter 182-502A WAC.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-23-009, s 182-502-0050, filed 11/8/24, effective 12/9/24. Statutory Authority: RCW 41.05.021. WSR 13-17-047, § 182-502-0050, filed 8/13/13, effective 10/1/13. WSR 11-14-075, recodified as § 182-502-0050, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0050, filed 5/9/11, effective 6/9/11.]

PDF182-502-0060

Reapplying for participation.

A provider who is terminated solely under WAC 182-502-0030(3) is eligible for immediate reapplication with the medicaid agency if the provider is not a full or partial owner of a terminated group practice.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-21-067, § 182-502-0060, filed 10/11/19, effective 11/11/19; WSR 15-15-050, § 182-502-0060, filed 7/9/15, effective 8/9/15. Statutory Authority: RCW 41.05.021. WSR 13-17-047, § 182-502-0060, filed 8/13/13, effective 10/1/13. WSR 11-14-075, recodified as § 182-502-0060, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0060, filed 5/9/11, effective 6/9/11.]

PDF182-502-0100

General conditions of payment.

(1) The medicaid agency pays for health care services furnished to an eligible client when the claim satisfies agency rules including all the following:

(a) The service is within the scope of care of the client's Washington apple health program;

(b) The service is medically necessary;

(d) The provider bills within the time frame set in WAC 182-502-0150;

(e) The provider bills according to agency rules and billing instructions; and

(f) The provider follows third-party payment procedures.

(2) The agency pays for health care services only when the services are provided by or on behalf of a provider that is enrolled with the agency.

(3) In order for any services or supplies ordered, prescribed, or referred by a provider to be paid:

(a) The provider must be enrolled with the agency under their national provider identifier (NPI); and

(b) The NPI for the referring, prescribing, or ordering provider must be included on the claim form.

(4) If payment for services is to be made to a group practice, partnership, or corporation, the group, partnership, or corporation must enroll with the agency and provide its national provider identifier (NPI) (if eligible for an NPI) to be used for submitting claims as the billing provider.

(5) The agency is the payer of last resort, unless the other payer is:

(a) An Indian health service;

(b) A crime victims program through the department of labor and industries; or

(6) The agency does not pay providers for health care services identified by the agency as client financial obligations, and deducts from the payment the costs of those services identified as client financial obligations. Client financial obligations include, but are not limited to, the following:

(a) Copayments (copays) (unless the criteria in chapter 182-517 WAC or WAC 182-501-0200 are met);

(b) Deductibles (unless the criteria in chapter 182-517 WAC or WAC 182-501-0200 are met); and

(7) The agency does not pay for any health care service, drug, supply, or equipment prescribed or ordered by a health care professional, health care entity, supplier, or contractor of service not currently enrolled with the agency.

(8) The agency does not pay for services provided to clients during the application process for provider enrollment, regardless of whether the agency later approves or denies the application, unless an exception for earlier enrollment is approved by the agency in accordance with WAC 182-502-0005.

(9) The agency does not pay for any health care service, drug, supply, or equipment prescribed or ordered by a health care professional, health care entity, supplier, or contractor of services whose application for enrollment has been denied or terminated.

(10) The provider must accept medicare assignment for claims involving clients eligible for both medicare and Washington apple health before the agency makes any payment.

(11) The provider is responsible for verifying whether a client has Washington apple health coverage for the dates of service.

(12) The agency may reimburse a provider for services provided to a person if it is later determined that the person was ineligible for the service when it was provided if:

(a) The agency considered the person eligible at the time of service;

(b) The service was not otherwise paid for; and

(13) The agency does not pay on a fee-for-service basis for a service for a client who is enrolled in a managed care plan when the service is included in the plan's contract with the agency.

(14) Information about health care services for jail inmates is found in RCW 70.48.130.

(15) The agency pays for medically necessary services on the basis of usual and customary charges or the maximum allowable fee established by the agency, whichever is lower.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-23-009, s 182-502-0100, filed 11/8/24, effective 12/9/24. Statutory Authority: RCW 41.05.021, 41.05.160, and P.L. 114-255. WSR 23-24-026, § 182-502-0100, filed 11/29/23, effective 1/1/24. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0100, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-11-014, § 388-502-0100, filed 5/9/11, effective 6/9/11; WSR 10-19-057, § 388-502-0100, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 71.05.560, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. WSR 06-13-042, § 388-502-0100, filed 6/15/06, effective 7/16/06. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.530. WSR 00-15-050, § 388-502-0100, filed 7/17/00, effective 8/17/00.]

PDF182-502-0110

Conditions of payment and prior authorization requirements—Medicare coinsurance, copayments, and deductibles.

(1) The following people are eligible for benefits under this section:

(a) Dual-eligible clients enrolled in categorically needy Washington apple health programs;

(b) Dual-eligible clients enrolled in medically needy Washington apple health programs; or

(2) The agency pays the medicare coinsurance, copayments, and deductibles for Part A, Part B, and medicare advantage Part C for an eligible person under subsection (1) of this section:

(a) Up to the published or calculated medicaid-only rate; and

(b) If the provider accepts assignment for medicare payment.

(3) If a medicare Part A recipient has remaining lifetime reserve days, the agency pays the deductible and coinsurance amounts up to the allowed amount as calculated by the agency.

(4) If a medicare Part A recipient has exhausted lifetime reserve days during an inpatient hospital stay, the agency pays the deductible and coinsurance amounts up to the agency-calculated allowed amount minus any payment made by medicare, and any payment made by the agency, up to the outlier threshold. Once the outlier threshold is reached, the agency pays according to WAC 182-550-3700.

(5) If medicare and medicaid cover the service, the agency pays:

(a) The deductible and coinsurance up to medicare or medicaid's allowed amount, whichever is less; or

(b) For long-term civil commitments, as defined in WAC 182-500-0065, the greater of medicare or medicaid's allowed amount, minus what medicare paid.

(6) If only medicare covers the service, the agency pays the deductible and coinsurance up to the agency's allowed amount established for a QMB client, and at zero for a non-QMB client.

(7) If a client exhausts medicare benefits, the agency pays for medicaid-covered services under Title 182 WAC and the agency's billing instructions.

(8) When medicaid requires prior authorization for a service covered by both medicare and medicaid:

(a) Medicaid does not require prior authorization when the client's medicare benefit is not exhausted.

(b) Medicaid does require prior authorization when the client's medicare benefit is exhausted. See also WAC 182-501-0050(5).

(9) Providers must meet the timely billing requirements under WAC 182-502-0150 in order to be paid for services.

(10) Payment for services is subject to postpayment review.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-17-167, § 182-502-0110, filed 8/24/22, effective 9/24/22; WSR 17-06-063, § 182-502-0110, filed 2/28/17, effective 3/31/17; WSR 16-13-157, § 182-502-0110, filed 6/22/16, effective 7/23/16. WSR 11-14-075, recodified as § 182-502-0110, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.530. WSR 00-15-050, § 388-502-0110, filed 7/17/00, effective 8/17/00.]

PDF182-502-0120

Payment for health care services provided outside the state of Washington.

(1) The medicaid agency pays for health care services provided outside the state of Washington only when the service meets the provisions described in WAC 182-501-0180, 182-501-0182, 182-501-0184, and specific program WAC.

(2) With the exception of hospital services and nursing facilities, the agency pays the provider of service in designated bordering cities as if the care was provided within the state of Washington (see WAC 182-501-0175).

(3) With the exception of designated bordering cities, the agency does not pay for health care services provided to clients in medical care services (MCS) programs outside the state of Washington.

(4) With the exception of hospital services (see subsection (5) of this section), the agency pays for health care services provided outside the state of Washington at the lower of:

(a) The billed amount; or

(b) The rate established by the Washington apple health programs.

(5) The agency pays for hospital services provided in designated bordering cities and outside the state of Washington under WAC 182-550-3900, 182-550-4000, 182-550-4800, and 182-550-6700.

(6) The agency pays nursing facilities located outside the state of Washington when approved by the aging and long-term support administration (ALTSA) at the lower of the billed amount or the adjusted statewide average reimbursement rate for in-state nursing facility care, only in the following limited circumstances:

(a) Emergency situations; or

(b) When the client intends to return to Washington state and the out-of-state stay is for:

(i) Thirty days or less; or

(ii) More than thirty days if approved by ALTSA.

(7) To receive payment from the agency, an out-of-state provider must:

(a) Have a signed agreement with the agency;

(b) Meet the functionally equivalent licensing requirements of the state or province in which care is rendered;

(d) Satisfy all medicaid conditions of participation;

(e) Accept the agency's payment as payment in full according to 42 C.F.R. 447.15; and

(f) If a Canadian provider, bill at the U.S. exchange rate in effect when the service was provided.

(8) For covered services for eligible clients, the agency reimburses other approved out-of-state providers at the lower of:

(a) The billed amount; or

(b) The rate paid by the Washington state Title XIX medicaid program.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0120, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0120, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-502-0120, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. WSR 08-08-064, § 388-502-0120, filed 3/31/08, effective 5/1/08. Statutory Authority: RCW 74.08.090. WSR 01-02-076, § 388-502-0120, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.04.050 and 74.08.090. WSR 00-01-088, § 388-502-0120, filed 12/14/99, effective 1/14/00.]

PDF182-502-0130

Interest penalties—Providers.

(1) Providers who are enrolled as contractors with the medicaid agency's medical care programs may be assessed interest on excess benefits or other inappropriate payments. Nursing home providers are governed by WAC 388-96-310 and are not subject to this section.

(2) The agency assesses interest when:

(a) The excess benefits or other inappropriate payments were not the result of agency error; and

(b) A provider is found liable for receipt of excess benefits or other payments under RCW 74.09.220; or

(3) The agency assesses interest at the rate of one percent for each month the overpayment is not satisfied. Daily interest calculations and assessments are made for partial months.

(4) Interest is calculated beginning from the date the agency receives payment from the provider. Interest ceases to be calculated and collected from the provider once the overpayment amount is received by the agency.

(5) The agency calculates interest and amounts, which are identified on all agency collection notices and statements.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0130, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0130, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050 and 74.08.090. WSR 00-01-088, recodified as § 388-502-0130, filed 12/14/99, effective 1/14/00. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-502-0250, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-044.]

PDF182-502-0150

Time limits for providers to bill the agency.

Providers must bill the medicaid agency for covered services provided to eligible clients as follows:

(1) The agency requires providers to submit initial claims and adjust prior claims in a timely manner. The agency has three timeliness standards:

(a) For initial claims, see subsections (3), (4), (5), and (6) of this section;

(b) For resubmitted claims other than prescription drug claims and claims for major trauma services, see subsections (7) and (8) of this section;

(d) For resubmitting claims for major trauma services, see subsection (11) of this section.

(2) The provider must submit claims to the agency as described in the agency's current published billing instructions.

(3) Providers must submit the initial claim to the agency and have a transaction control number (TCN) assigned by the agency within three hundred sixty-five calendar days from any of the following:

(a) The date the provider furnishes the service to the eligible client;

(b) The date a final fair hearing decision is entered that impacts the particular claim;

(d) The date the agency certifies a client eligible under delayed certification criteria.

(4) The agency may grant exceptions to the time limit of three hundred sixty-five calendar days for initial claims when billing delays are caused by either of the following:

(a) The agency's certification of a client for a retroactive period; or

(b) The provider proves to the agency's satisfaction that there are other extenuating circumstances.

(5) The agency requires providers to bill known third parties for services. See WAC 182-501-0200 for exceptions. Providers must meet the timely billing standards of the liable third parties in addition to the agency's billing limits.

(6) When a client is covered by both medicare and medicaid, the provider must bill medicare for the service before billing the initial claim to the agency. If medicare:

(a) Pays the claim the provider must bill the agency within six months of the date medicare processes the claim; or

(b) Denies payment of the claim, the agency requires the provider to meet the three hundred sixty-five-day requirement for timely initial claims as described in subsection (3) of this section.

(7) Within twenty-four months of the date the service was provided to the client, a provider may resubmit, modify, or adjust an initial claim, other than a prescription drug claim or a claim for major trauma services.

(8) After twenty-four months from the date the service was provided to the client, the agency does not accept any claim for resubmission, modification, or adjustment. This twenty-four-month period does not apply to overpayments that a provider must refund to the agency by a negotiable financial instrument, such as a bank check.

(9) The agency allows providers to resubmit, modify, or adjust any prescription drug claim with a timely TCN within fifteen months of the date the service was provided to the client. After fifteen months, the agency does not accept any prescription drug claim for resubmission, modification, or adjustment.

(10) The fifteen-month period described in subsection (9) of this section does not apply to overpayments that a prescription drug provider must refund to the agency. After fifteen months a provider must refund overpayments by a negotiable financial instrument, such as a bank check.

(11) The agency allows a provider of trauma care services to resubmit, modify, or adjust, within three hundred and sixty-five calendar days of the date of service, any trauma claim that meets the criteria specified in WAC 182-531-2000 (for physician claims) or WAC 182-550-5450 (for hospital claims) for the purpose of receiving payment from the trauma care fund (TCF).

(a) No increased payment from the TCF is allowed for an otherwise qualifying trauma claim that is resubmitted after three hundred sixty-five calendar days from the date of service.

(b) Resubmission of or any adjustments to a trauma claim for purposes other than receiving TCF payments are subject to the provisions of this section.

(12) The three hundred sixty-five-day period described in subsection (11) of this section does not apply to overpayments from the TCF that a trauma care provider must refund to the agency. A provider must refund an overpayment for a trauma claim that received payment from TCF using a method specified by the agency.

(13) If a provider fails to bill a claim according to the requirements of this section and the agency denies payment of the claim, the provider or any provider's agent cannot bill the client or the client's estate. The client is not responsible for the payment.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0150, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-502-0150, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-063, § 388-502-0150, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090 and 42 C.F.R. 447.45. WSR 00-14-067, § 388-502-0150, filed 7/5/00, effective 8/5/00.]

PDF182-502-0160

Billing a client.

(1) The purpose of this section is to specify the limited circumstances in which:

(a) Fee-for-service or managed care clients can choose to self-pay for medical assistance services; and

(b) Providers (as defined in WAC 182-500-0085) have the authority to bill fee-for-service or managed care clients for medical assistance services furnished to those clients.

(2) The provider is responsible for:

(a) Verifying whether the client is eligible to receive medical assistance services on the date the services are provided;

(b) Verifying whether the client is enrolled with a medicaid agency-contracted managed care organization (MCO);

(c) Knowing the limitations of the services within the scope of the eligible client's medical program (see WAC 182-501-0050 (4)(a) and 182-501-0065);

(d) Informing the client of those limitations;

(e) Exhausting all applicable medicaid agency or agency-contracted MCO processes necessary to obtain authorization for requested service(s);

(f) Ensuring that translation or interpretation is provided to clients with limited English proficiency (LEP) who agree to be billed for services in accordance with this section; and

(g) Retaining all documentation which demonstrates compliance with this section.

(3) Unless otherwise specified in this section, providers must accept as payment in full the amount paid by the agency or agency-contracted MCO for medical assistance services furnished to clients. See 42 C.F.R. § 447.15.

(4) A provider must not bill a client, or anyone on the client's behalf, for any services until the provider has completed all requirements of this section, including the conditions of payment described in the agency's rules, the agency's fee-for-service billing instructions, and the requirements for billing the agency-contracted MCO in which the client is enrolled, and until the provider has then fully informed the client of his or her covered options. A provider must not bill a client for:

(a) Any services for which the provider failed to satisfy the conditions of payment described in the agency's rules, the agency's fee-for-service billing instructions, and the requirements for billing the agency-contracted MCO in which the client is enrolled.

(b) A covered service even if the provider has not received payment from the agency or the client's MCO.

(c) A covered service when the agency or its designee denies an authorization request for the service because the required information was not received from the provider or the prescriber under WAC 182-501-0165 (7)(c)(i).

(5) If the requirements of this section are satisfied, then a provider may bill a fee-for-service or a managed care client for a covered service, defined in WAC 182-501-0050(9), or a noncovered service, defined in WAC 182-501-0050(10) and 182-501-0070. The client and provider must sign and date the HCA form 13-879, Agreement to Pay for Healthcare Services, before the service is furnished. Form 13-879, including translated versions, is available to download at http://hrsa.dshs.wa.gov/mpforms.shtml. The requirements for this subsection are as follows:

(a) The agreement must:

(i) Indicate the anticipated date the service will be provided, which must be no later than ninety calendar days from the date of the signed agreement;

(ii) List each of the services that will be furnished;

(iii) List treatment alternatives that may have been covered by the agency or agency-contracted MCO;

(iv) Specify the total amount the client must pay for the service;

(v) Specify what items or services are included in this amount (such as preoperative care and postoperative care). See WAC 182-501-0070(3) for payment of ancillary services for a noncovered service;

(vi) Indicate that the client has been fully informed of all available medically appropriate treatment, including services that may be paid for by the agency or agency-contracted MCO, and that he or she chooses to get the specified service(s);

(vii) Specify that the client may request an exception to rule (ETR) in accordance with WAC 182-501-0160 when the agency or its designee denies a request for a noncovered service and that the client may choose not to do so;

(viii) Specify that the client may request an administrative hearing in accordance with chapter 182-526 WAC to appeal the agency's or its designee denial of a request for prior authorization of a covered service and that the client may choose not to do so;

(ix) Be completed only after the provider and the client have exhausted all applicable agency or agency-contracted MCO processes necessary to obtain authorization of the requested service, except that the client may choose not to request an ETR or an administrative hearing regarding agency or agency designee denials of authorization for requested service(s); and

(x) Specify which reason in subsection (b) below applies.

(b) The provider must select on the agreement form one of the following reasons (as applicable) why the client is agreeing to be billed for the service(s). The service(s) is:

(i) Not covered by the agency or the client's agency-contracted MCO and the ETR process as described in WAC 182-501-0160 has been exhausted and the service(s) is denied;

(ii) Not covered by the agency or the client's agency-contracted MCO and the client has been informed of his or her right to an ETR and has chosen not to pursue an ETR as described in WAC 182-501-0160;

(iii) Covered by the agency or the client's agency-contracted MCO, requires authorization, and the provider completes all the necessary requirements; however the agency or its designee denied the service as not medically necessary (this includes services denied as a limitation extension under WAC 182-501-0169); or

(iv) Covered by the agency or the client's agency-contracted MCO and does not require authorization, but the client has requested a specific type of treatment, supply, or equipment based on personal preference which the agency or MCO does not pay for and the specific type is not medically necessary for the client.

(c) For clients with limited English proficiency, the agreement must be the version translated in the client's primary language and interpreted if necessary. If the agreement is translated, the interpreter must also sign it;

(d) The provider must give the client a copy of the agreement and maintain the original and all documentation which supports compliance with this section in the client's file for six years from the date of service. The agreement must be made available to the agency or its designee for review upon request; and

(e) If the service is not provided within ninety calendar days of the signed agreement, a new agreement must be completed by the provider and signed by both the provider and the client.

(6) There are limited circumstances in which a provider may bill a client without executing form 13-879, Agreement to Pay for Healthcare Services, as specified in subsection (5) of this section. The following are those circumstances:

(a) The client, the client's legal guardian, or the client's legal representative:

(i) Was reimbursed for the service directly by a third party (see WAC 182-501-0200); or

(ii) Refused to complete and sign insurance forms, billing documents, or other forms necessary for the provider to bill the third party insurance carrier for the service.

(b) The client represented himself/herself as a private pay client and not receiving medical assistance when the client was already eligible for and receiving benefits under a medical assistance program. In this circumstance, the provider must:

(i) Keep documentation of the client's declaration of medical coverage. The client's declaration must be signed and dated by the client, the client's legal guardian, or the client's legal representative; and

(ii) Give a copy of the document to the client and maintain the original for six years from the date of service, for agency or the agency's designee review upon request.

(c) The bill counts toward the financial obligation of the client or applicant (such as spenddown liability, client participation as described in chapters 182-513 and 182-515 WAC, emergency medical expense requirement, deductible, or copayment required by the agency or its designee). See subsection (7) of this section for billing a medically needy client for spenddown liability;

(d) The client is placed in the agency's or an agency-contracted MCO's patient review and coordination (PRC) program and obtains nonemergency services from a nonpharmacy provider that is not an assigned or appropriately referred provider as described in WAC 182-501-0135;

(e) The client is a dual-eligible client with medicare Part D coverage or similar creditable prescription drug coverage and the conditions of WAC 182-530-7700 (2)(a)(iii) are met;

(f) The service is within a service category excluded from the client's benefits package. See WAC 182-501-0060;

(g) The services were noncovered ambulance services (see WAC 182-546-0250(2));

(h) A fee-for-service client chooses to receive nonemergency services from a provider who is not contracted with the agency or its designee after being informed by the provider that he or she is not contracted with the agency or its designee and that the services offered will not be paid by the client's health care program; and

(i) An agency-contracted MCO enrollee chooses to receive nonemergency services from providers outside of the MCO's network without authorization from the MCO, i.e., a nonparticipating provider.

(7) Under chapter 182-519 WAC, an individual who has applied for medical assistance is required to spend down excess income on health care expenses to become eligible for coverage under the medically needy program. An individual must incur health care expenses greater than or equal to the amount that he or she must spend down. The provider is prohibited from billing the individual for any amount in excess of the spenddown liability assigned to the bill.

(8) There are situations in which a provider must refund the full amount of a payment previously received from or on behalf of an individual and then bill the agency for the covered service that had been furnished. In these situations, the individual becomes eligible for a covered service that had already been furnished. Providers must then accept as payment in full the amount paid by the agency or its designee or managed care organization for medical assistance services furnished to clients. These situations are as follows:

(a) The individual was not receiving medical assistance on the day the service was furnished. The individual applies for medical assistance later in the same month in which the service was provided and the agency or its designee makes the individual eligible for medical assistance from the first day of that month;

(b) The client receives a delayed certification for medical assistance as defined in WAC 182-500-0025; or

(c) The client receives a certification for medical assistance for a retroactive period according to 42 C.F.R. § 435.914(a) and defined in WAC 182-500-0095.

(9) Regardless of any written, signed agreement to pay, a provider may not bill, demand, collect, or accept payment or a deposit from a client, anyone on the client's behalf, or the agency or its designee for:

(a) Copying, printing, or otherwise transferring health care information, as the term health care information is defined in chapter 70.02 RCW, to another health care provider. This includes, but is not limited to:

(i) Medical/dental charts;

(ii) Radiological or imaging films; and

(iii) Laboratory or other diagnostic test results.

(b) Missed, canceled, or late appointments;

(d) "Boutique," "concierge," or enhanced service packages (e.g., newsletters, 24/7 access to provider, health seminars) as a condition for access to care; or

(e) The price differential between an authorized service or item and an "upgraded" service or item (e.g., a wheelchair with more features; brand name versus generic drugs).

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-08-075, § 182-502-0160, filed 4/3/18, effective 5/4/18. Statutory Authority: RCW 41.05.021. WSR 13-15-044, § 182-502-0160, filed 7/11/13, effective 8/11/13. Statutory Authority: RCW 41.05.021 and section 1927 of the Social Security Act. WSR 12-18-062, § 182-502-0160, filed 8/31/12, effective 10/1/12. WSR 11-14-075, recodified as § 182-502-0160, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-502-0160, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090 and 42 C.F.R. 447.15. WSR 10-10-022, § 388-502-0160, filed 4/26/10, effective 5/27/10. Statutory Authority: RCW 74.08.090, 74.09.055, 2001 c 7, Part II. WSR 02-12-070, § 388-502-0160, filed 5/31/02, effective 7/1/02. Statutory Authority: RCW 74.08.090. WSR 01-21-023, § 388-502-0160, filed 10/8/01, effective 11/8/01; WSR 01-05-100, § 388-502-0160, filed 2/20/01, effective 3/23/01. Statutory Authority: RCW 74.08.090 and 74.09.520. WSR 00-14-069, § 388-502-0160, filed 7/5/00, effective 8/5/00.]

PDF182-502-0210

Statistical data-provider reports.

(1) At the request of the medicaid agency, all providers enrolled with agency programs must submit full reports, as specified by the agency, of goods and services furnished to eligible Washington apple health clients. The agency furnishes the provider with a standardized format to report these data.

(2) The agency analyzes the data collected from the providers' reports to secure statistics on costs of goods and services furnished and makes a report of the analysis available to the agency's advisory committee, the state welfare medical care committee, representative organizations of provider groups enrolled with the agency, and any other interested organizations or individuals.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0210, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0210, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-502-0210, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.035. WSR 00-15-049, § 388-502-0210, filed 7/17/00, effective 8/17/00. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-502-0210, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-020.]

PDF182-502-0220

Administrative appeal contractor or provider rate reimbursement.

(1) Any enrolled contractor or provider of medical services has a right to an administrative appeal when the contractor or provider disagrees with the medicaid agency reimbursement rate. The exception to this is nursing facilities governed by WAC 388-96-904.

(2) The first level of appeal. A contractor or provider who wants to contest a reimbursement rate must file a written appeal with the agency.

(a) The appeal must include the following:

(i) A statement of the specific issue being appealed;

(ii) Supporting documentation; and

(iii) A request for the agency to recalculate the rate.

(b) When a contractor or provider appeals a portion of a rate, the agency may review all components of the reimbursement rate.

(i) Request additional information; and

(ii) Conduct an audit of the documentation provided.

(d) The agency issues a decision or requests additional information within sixty calendar days of receiving the rate appeal request.

(i) When the agency requests additional information, the contractor or provider has forty-five calendar days from the date of the agency's request to submit the additional information.

(ii) The agency issues a decision within thirty calendar days of receipt of the completed information.

(e) The agency may adjust rates retroactively to the effective date of a new rate or a rate change. In order for a rate increase to be retroactive, the contractor or provider must file the appeal within sixty calendar days of the date of the rate notification letter from the agency. The agency does not consider any appeal filed after the sixty-day period to be eligible for retroactive adjustment.

(f) The agency may grant a time extension for the appeal period if the contractor or provider makes such a request within the sixty-day period described in (e) of this subsection.

(g) Any rate increase resulting from an appeal filed within the sixty-day period described in subsection (2)(e) of this section is effective retroactively to the rate effective date in the notification letter.

(h) Any rate increase resulting from an appeal filed after the sixty-day period described in subsection (2)(e) of this section is effective on the date the rate appeal is received by the agency.

(i) Any rate decrease resulting from an appeal is effective on the date specified in the appeal decision letter.

(j) Any rate change that the agency grants that is the result of fraudulent practices on the part of the contractor or provider as described under RCW 74.09.210 is exempt from the appeal provisions in this chapter.

(3) The second level of appeal. When the contractor or provider disagrees with a rate review decision, it may file a request for a dispute conference with the agency. For this section "dispute conference" means an informal administrative hearing to resolve contractor or provider disagreements with an agency action as described under subsection (1) of this section and not agreed upon at the first level of appeal. The dispute conference is not governed by the Administrative Procedure Act, chapter 34.05 RCW.

(a) If a contractor or provider files a request for a dispute conference, it must submit the request to the agency within thirty calendar days after the contractor or provider receives the rate review decision. The agency does not consider dispute conference requests submitted after the thirty-day period for the first level decision.

(b) The agency conducts the dispute conference within ninety calendar days of receiving the request.

(c) An agency-appointed conference chairperson issues the final decision within thirty calendar days of the conference. Extensions of time for extenuating circumstances may be granted if all parties agree.

(d) Any rate increase or decrease resulting from a dispute conference decision is effective on the date specified in the dispute conference decision.

(e) The dispute conference is the final level of administrative appeal within the agency and precedes judicial action.

(4) The agency considers that a contractor or provider who fails to attempt to resolve disputed rates as provided in this section has abandoned the dispute.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0220, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0220, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 10-19-057, § 388-502-0220, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090 and 74.09.730. WSR 99-16-070, § 388-502-0220, filed 8/2/99, effective 9/2/99. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-502-0220, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-043.]

PDF182-502-0230

Provider overpayment disputes—General.

(1) This section applies to provider overpayment disputes with providers who furnish health care services to Washington apple health clients, except those overpayment disputes to which chapter 182-502A WAC applies. For the purposes of this section:

(a) "Agency" means the health care authority and its designees.

(b) "Provider" has the same meaning as vendor in RCW 41.05A.010(5).

(2) If the medicaid agency determines that a provider was overpaid, the agency may take any of the following actions:

(a) Review claims, encounters, or payments;

(b) Refer the provider to the agency's office of program integrity;

(d) Refer the provider to the appropriate state health care professional discipline authority;

(e) Terminate the provider's participation in Washington apple health;

(f) Assess a civil penalty against the provider, per RCW 74.09.210;

(g) In the event of a prepay review, suspend some or all payments;

(h) Adjust or void an improper claim, encounter, or payment;

(i) Recover any moneys that the provider received as a result of overpayments as authorized under chapter 41.05A RCW; and

(j) Any other action authorized by Title 182 WAC.

(3) A provider may contest an overpayment by requesting a hearing.

(4) The hearing request must:

(a) Be in writing;

(b) Identify each overpayment being contested;

(d) Include documentation to support the provider's position; and

(e) Include a copy of the overpayment notice.

(5) The hearing request must be served on the agency at the address specified in the overpayment notice, in a manner which provides proof of receipt, no later than twenty-eight calendar days after the provider received the overpayment notice.

(6) The hearing is conducted under the Administrative Procedure Act and chapter 182-526 WAC.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-01-056, § 182-502-0230, filed 12/10/14, effective 1/10/15. WSR 11-14-075, recodified as § 182-502-0230, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0230, filed 5/9/11, effective 6/9/11. Statutory Authority: RCW 74.08.090, 74.09.520, 34.05.020, 34.05.220. WSR 00-22-017, § 388-502-0230, filed 10/20/00, effective 11/20/00. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-502-0230, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-042.]

PDF182-502-0260

Appeals and dispute resolution for providers with contracts other than core provider agreements.

(1) Providers of medical services who have a contract, other than a core provider agreement, with a dispute resolution provision must follow the dispute resolution process described in the contract.

(2) See WAC 182-502-0220 for disputes involving rates. See chapter 182-502A WAC for disputes involving audits. See WAC 182-502-0230 for disputes involving provider reviews and termination.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-039, § 182-502-0260, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-502-0260, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.290. WSR 00-22-016, § 388-502-0260, filed 10/20/00, effective 11/20/00.]

PDF182-502-0270

Review of agency's provider dispute decision.

(1) This section applies only when agency rules allow review of an agency dispute decision under this section. The director of the health care authority or designee conducts the review.

(2) Providers and former providers may request a review of an agency dispute decision. The request must be in writing and sent to: Health Care Authority, Attn: Appeals Administrator, P.O. Box 45504, Olympia, WA 98504-5504. The agency must receive the written dispute review request within twenty-eight calendar days of the date on the agency's written dispute decision.

(3) When the agency receives a timely dispute review request, the director or designee may schedule a dispute review conference. "Dispute review conference" means an informal conference for the purpose of resolving disagreements between the agency and a provider or former provider who is dissatisfied with an agency decision. The dispute review conference is not governed by the Administrative Procedure Act, chapter 34.05 RCW. If the director or designee chooses to schedule a dispute review conference, the director or designee will conduct the conference within ninety calendar days of the dispute review request unless the director or designee and the party requesting review agree to an extension.

(4) The director or designee will issue a dispute review decision to the provider or former provider requesting review within thirty calendar days of receiving the dispute review request or within thirty calendar days of the dispute review conference, whichever is later, unless both parties agree to an extension.

(5) The director review is the final level of agency review for disputes to which this section applies.

[Statutory Authority: RCW 41.05.021. WSR 13-17-047, § 182-502-0270, filed 8/13/13, effective 10/1/13. WSR 11-14-075, recodified as § 182-502-0270, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 08-12-012, § 388-502-0270, filed 5/27/08, effective 6/27/08.]