WSR 00-23-051

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed November 13, 2000, 3:22 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 00-10-032.

Title of Rule: WAC 388-501-0050 Medical and dental general coverage.

Purpose: To explain the criteria for determining if services, equipment, and supplies are covered by the Medical Assistance Administration.

Statutory Authority for Adoption: RCW 74.08.090.

Statute Being Implemented: RCW 74.08.090.

Summary: This proposed rule explains how to determine if a service or equipment is covered or noncovered, and conditions that may be placed on coverage, such as prior authorization, expedited prior authorization and/or service limitations.

Reasons Supporting Proposal: To clearly explain the process used to determine if the department covers or does not cover a service or equipment.

Name of Agency Personnel Responsible for Drafting: Leslie Saeger, P.O. Box 45533, Olympia, WA 98504, (360) 725-1347; Implementation and Enforcement: Sharon Morrison, P.O. Box 45533, Olympia, WA 98504, (360) 725-1347.

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

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

Explanation of Rule, its Purpose, and Anticipated Effects: The proposed rule will not change the way MAA currently does business. This rule explains how to determine if MAA covers or does not cover a service or equipment, and where to get more information about conditions that may be placed on certain services or equipment, such as prior authorization, expedited prior authorization, and limitation extensions.

     The terms "covered" and "noncovered" are used throughout MAA WACs. This WAC is intended to explain these terms. As rules are sunset reviewed, MAA intends to delete duplication that will exist in other MAA rules as a result of codifying this rule.

Proposal Changes the Following Existing Rules: WAC 388-501-0050, amends, see proposed rules.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rules and concludes that they do not change existing policy, and so will not have a more than minor impact on the businesses affected by them.

RCW 34.05.328 does not apply to this rule adoption. The department has analyzed the proposed rule and concludes that it does not make "significant amendments to a policy or regulatory program" since no policy changes have been made. Therefore, the department concludes that the proposed rules do not meet the definition of significant legislative rules.

Hearing Location: Blake Office Building East, 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on January 3, 2001, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Kelly Cooper, Rules Coordinator, by December 27, 2000, phone (360) 664-6094, TTY (360) 664-6178, e-mail coopeKD@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, Kelly Cooper, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 902-8292, by January 3, 2001.

Date of Intended Adoption: No sooner than January 4, 2001.

November 8, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

2876.2
AMENDATORY SECTION(Amending WSR 00-01-088, filed 12/14/99, effective 1/14/00)

WAC 388-501-0050
Medical ((services requiring approval)) and dental general coverage.

All medical and dental services ((that are provided to clients of medical care programs are subject to review and approval for reimbursement by the)), equipment, and supplies provided to medical assistance administration (MAA) clients are subject to review, before or after payment has been made. MAA may deny or recover reimbursement for such services, equipment, and supplies based on these reviews.

     (1) Covered Services

     (a) Covered services are:

     (i) Medical and dental services, equipment, and supplies that are within the scope of the eligible client's medical assistance program (see chapter 388-529 WAC) and listed as covered in MAA rules, billing instructions, or numbered memoranda; and

     (ii) Determined by MAA to be medically necessary as defined in WAC 388-500-0005 or dentally necessary as defined in WAC 388-535-0150.

     (b) Providers must obtain prior authorization or expedited prior authorization when required by WAC, billing instructions, or numbered memoranda.

     (i) See WAC 388-501-0165 for the prior authorization (PA) process.

     (ii) See MAA billing instructions for specific criteria for the expedited prior authorization (EPA) process.

     (iii) See chapter 388-538 WAC for managed care requirements.

     (c) Covered services are subject to the limitations specified in WAC, billing instructions, or numbered memoranda. Providers must obtain prior authorization or expedited prior authorization before providing services that exceed the specified limit (quantity, frequency or duration). This is known as a limitation extension.

     (i) See WAC 388-501-0165 for the prior authorization (PA) process.

     (ii) See MAA billing instructions for specific criteria for the expedited prior authorization (EPA) process.

     (iii) See chapter 388-538 WAC for managed care requirements.

     (d) MAA does not reimburse for covered services, equipment or supplies that are:

     (i) Included in a waivered program, e.g., COPES; or

     (ii) Part of one of the Medicare programs for qualified Medicare beneficiaries.

     (2) Noncovered services

     (a) MAA does not cover services, equipment or supplies to which any of the following apply:

     (i) The service or equipment is not included as a covered service in the state plan;

     (ii) Federal or state laws or regulations prohibit coverage;

     (iii) The service or equipment is considered experimental or investigational by the Food and Drug Administration or the Health Care Financing Administration; or

     (iv) MAA rules, billing instructions, or numbered memoranda do not list the service or equipment as covered.

     (b) If a noncovered service, equipment or supply is required under the EPSDT/Healthy Kids program, it will be reviewed for medical necessity as a covered service.

     (c) MAA reviews all initial requests for noncovered services based on WAC 388-501-0165.

[Statutory Authority: RCW 74.04.050 and 74.08.090.      00-01-088, § 388-501-0050, filed 12/14/99, effective 1/14/00.]

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