WSR 00-07-044

EXPEDITED ADOPTION

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed March 6, 2000, 3:21 p.m. ]

Title of Rule: WAC 388-501-0200 Third party resources.

Purpose: To correct a cross-reference to a WAC number that has been repealed, and identify the correct cross-reference.

Statutory Authority for Adoption: RCW 74.04.050, 74.08.090.

Statute Being Implemented: RCW 74.04.050, 74.08.090.

Summary: This WAC contains a cross-reference to a WAC number that has been repealed and replaced with a new number. The cross-reference in this WAC section is being replaced with the correct number. This is a housekeeping action only.

Reasons Supporting Proposal: This action is necessary in order for the cross-reference to be correct.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Ann Myers, DPS/RIP, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1345.

Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: This action is to replace with the correct number a cross-reference to a WAC number that has been repealed.

The purpose of this action is to correct the cross-reference for accuracy.

The anticipated effect will be to refer the user to the correct WAC.

Proposal Changes the Following Existing Rules: WAC 388-501-0200 will be amended to replace the cross-reference to WAC 388-87-020 with the correct reference of WAC 388-501-0100.

NOTICE

THIS RULE IS BEING PROPOSED TO BE ADOPTED USING AN EXPEDITED RULE-MAKING PROCESS THAT WILL ELIMINATE THE NEED FOR THE AGENCY TO HOLD PUBLIC HEARINGS, PREPARE A SMALL BUSINESS ECONOMIC IMPACT STATEMENT, OR PROVIDE RESPONSES TO THE CRITERIA FOR A SIGNIFICANT LEGISLATIVE RULE. IF YOU OBJECT TO THIS RULE BEING ADOPTED USING THE EXPEDITED RULE-MAKING PROCESS, YOU MUST EXPRESS YOUR OBJECTIONS IN WRITING AND THEY MUST BE SENT TO Paige Wall, Rules Coordinator, Department of Social and Health Services, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185 , AND RECEIVED BY May 22, 2000.


February 29, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

2716.1
AMENDATORY SECTION(Amending WSR 00-01-088, filed 12/14/99, effective 1/14/00)

WAC 388-501-0200
Third-party resources.

(1) MAA requires a provider to seek timely reimbursement from a third party when a client has available third-party resources, except as described under subsections (2) and (3) of this section.

(2) MAA pays for medical services and seeks reimbursement from the liable third party when the claim is for any of the following:

(a) Prenatal care;

(b) Labor, delivery, and postpartum care (except inpatient hospital costs) for a pregnant woman; or

(c) Preventive pediatric services as covered under the EPSDT program.

(3) MAA pays for medical services and seeks reimbursement from any liable third party when both of the following apply:

(a) The provider submits to MAA documentation of billing the third party and the provider has not received payment after thirty days from the date of services; and

(b) The claim is for a covered service provided to a client on whose behalf the office of support enforcement is enforcing an absent parent to pay support.      For the purpose of this section, "is enforcing" means the absent parent either:

(i) Is not complying with an existing court order; or

(ii) Received payment directly from the third party and did not pay for the medical services.

(4) The provider may not bill MAA or the client for a covered service when a third party pays a provider the same amount as or more than the MAA rate.

(5) When the provider receives payment from the third party after receiving reimbursement from MAA, the provider must refund to MAA the amount of the:

(a) Third-party payment when the payment is less than MAA's maximum allowable rate; or

(b) MAA payment when the third-party payment is equal to or greater than MAA's maximum allowable rate.

(6) MAA is not responsible to pay for medical services when the third-party benefits are available to pay for the client's medical services at the time the provider bills MAA, except as described under subsections (2) and (3) of this section.

(7) The client is liable for charges for covered medical services that would be paid by the third party payment when the client either:

(a) Receives direct third-party reimbursement for such services; or

(b) Fails to execute legal signatures on insurance forms, billing documents, or other forms necessary to receive insurance payments for services rendered.      See WAC 388-505-0540 for assignment of rights.

(8) MAA considers an adoptive family to be a third-party resource for the medical expenses of the birth mother and child only when there is a written contract between the adopting family and either the birth mother, the attorney, the provider, or the adoption service.      The contract must specify that the adopting family will pay for the medical care associated with the pregnancy.

(9) A provider cannot refuse to furnish covered services to a client because of a third party's potential liability for the services.

(10) For third-party liability on personal injury litigation claims, MAA is responsible for providing medical services as described under WAC ((388-87-020)) 388-501-0100.

[Statutory Authority: RCW 74.04.050 and 74.08.090.      00-01-088, § 388-501-0200, filed 12/14/99, effective 1/14/00.]

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