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182-501-0163  <<  182-501-0165 >>   182-501-0169

WAC 182-501-0165

Agency filings affecting this section

Medical and dental coverage—Fee-for-service (FFS) prior authorization—Determination process for payment.

(1) This section applies to fee-for-service (FFS) requests for medical or dental services and medical equipment that:
(a) Are identified as covered services or EPSDT services; and
(b) Require prior authorization by the department.
(2) The following definitions and those found in WAC 388-500-0005 apply to this section:
"Controlled studies" - Studies in which defined groups are compared with each other to reduce bias.
"Credible evidence" - Type I-IV evidence or evidence-based information from any of the following sources:
• Clinical guidelines
• Government sources
• Independent medical evaluation (IME)
• Independent review organization (IRO)
• Independent technology assessment organizations
• Medical and hospital associations
• Policies of other health plans
• Regulating agencies (e.g., Federal Drug Administration or Department of Health)
• Treating provider
• Treatment pathways
"Evidence-based" - The ordered and explicit use of the best evidence available (see "hierarchy of evidence" in subsection (6)(a) of this section) when making health care decisions.
"Health outcome" - Changes in health status (mortality and morbidity) which result from the provision of health care services.
"Institutional review board (IRB)" - A board or committee responsible for reviewing research protocols and determining whether:
(1) The rights and welfare of human subjects are adequately protected;
(2) The risks to individuals are minimized and are not unreasonable;
(3) The risks to individuals are outweighed by the potential benefit to them or by the knowledge to be gained; and
(4) The proposed study design and methods are adequate and appropriate in the light of stated study objectives.
"Independent review organization (IRO)" - A panel of medical and benefit experts intended to provide unbiased, independent, clinical, evidence-based reviews of adverse decisions.
"Independent medical evaluation (IME)" - An objective medical examination of the client to establish the medical facts.
"Provider" - The individual who is responsible for diagnosing, prescribing, and providing medical, dental, or mental health services to department clients.
(3) The department authorizes, on a case-by-case basis, requests described in subsection (1) when the department determines the service or equipment is medically necessary as defined in WAC 388-500-0005. The process the department uses to assess medical necessity is based on:
(a) The evaluation of submitted and obtainable medical, dental, or mental health evidence as described in subsections (4) and (5) of this section; and
(b) The application of the evidence-based rating process described in subsection (6) of this section.
(4) The department reviews available evidence relevant to a medical, dental, or mental health service or equipment to:
(a) Determine its efficacy, effectiveness, and safety;
(b) Determine its impact on health outcomes;
(c) Identify indications for use;
(d) Evaluate pertinent client information;
(e) Compare to alternative technologies; and
(f) Identify sources of credible evidence that use and report evidence-based information.
(5) The department considers and evaluates all available clinical information and credible evidence relevant to the client's condition. At the time of request, the provider responsible for the client's diagnosis and/or treatment must submit credible evidence specifically related to the client's condition, including but not limited to:
(a) A client-specific physiological description of the disease, injury, impairment, or other ailment;
(b) Pertinent laboratory findings;
(c) Pertinent X-ray and/or imaging reports;
(d) Individual patient records pertinent to the case or request;
(e) Photographs and/or videos when requested by the department; and
(f) Objective medical/dental/mental health information such as medically/dentally acceptable clinical findings and diagnoses resulting from physical or mental examinations.
(6) The department uses the following processes to determine whether a requested service described in subsection (1) is medically necessary:
(a) Hierarchy of evidence - How defined. The department uses a hierarchy of evidence to determine the weight given to available data. The weight of medical evidence depends on objective indicators of its validity and reliability including the nature and source of the evidence, the empirical characteristics of the studies or trials upon which the evidence is based, and the consistency of the outcome with comparable studies. The hierarchy (in descending order with Type I given the greatest weight) is:
(i) Type I: Meta-analysis done with multiple, well-designed controlled studies;
(ii) Type II: One or more well-designed experimental studies;
(iii) Type III: Well-designed, quasi-experimental studies such as nonrandomized controlled, single group pre-post, cohort, time series, or matched case-controlled studies;
(iv) Type IV: Well-designed, nonexperimental studies, such as comparative and correlation descriptive, and case studies (uncontrolled); and
(v) Type V: Credible evidence submitted by the provider.
(b) Hierarchy of evidence - How classified. Based on the quality of available evidence, the department determines if the requested service is effective and safe for the client by classifying it as an "A," "B," "C," or "D" level of evidence:
(i) "A" level evidence: Shows the requested service or equipment is a proven benefit to the client's condition by strong scientific literature and well-designed clinical trials such as Type I evidence or multiple Type II evidence or combinations of Type II, III or IV evidence with consistent results (An "A" rating cannot be based on Type III or Type IV evidence alone).
(ii) "B" level evidence: Shows the requested service or equipment has some proven benefit supported by:
(A) Multiple Type II or III evidence or combinations of Type II, III or IV evidence with generally consistent findings of effectiveness and safety (A "B" rating cannot be based on Type IV evidence alone); or
(B) Singular Type II, III, or IV evidence in combination with department-recognized:
(I) Clinical guidelines; or
(II) Treatment pathways; or
(III) Other guidelines that use the hierarchy of evidence in establishing the rationale for existing standards.
(iii) "C" level evidence: Shows only weak and inconclusive evidence regarding safety and/or efficacy such as:
(A) Type II, III, or IV evidence with inconsistent findings; or
(B) Only Type V evidence is available.
(iv) "D" level evidence: Is not supported by any evidence regarding its safety and efficacy, for example that which is considered investigational or experimental.
(c) Hierarchy of evidence - How applied. After classifying the available evidence, the department:
(i) Approves "A" and "B" rated requests if the service or equipment:
(A) Does not place the client at a greater risk of mortality or morbidity than an equally effective alternative treatment; and
(B) Is not more costly than an equally effective alternative treatment.
(ii) Approves a "C" rated request only if the provider shows the requested service is the optimal intervention for meeting the client's specific condition or treatment needs, and:
(A) Does not place the client at a greater risk of mortality or morbidity than an equally effective alternative treatment; and
(B) Is less costly to the department than an equally effective alternative treatment; and
(C) Is the next reasonable step for the client in a well-documented tried-and-failed attempt at evidence-based care.
(iii) Denies "D" rated requests unless:
(A) The requested service or equipment has a humanitarian device exemption from the Food And Drug Administration (FDA); or
(B) There is a local institutional review board (IRB) protocol addressing issues of efficacy and safety of the requested service that satisfies both the department and the requesting provider.
(7) Within fifteen days of receiving the request from the client's provider, the department reviews all evidence submitted and:
(a) Approves the request;
(b) Denies the request if the requested service is not medically necessary; or
(c) Requests the provider submit additional justifying information. The department sends a copy of the request to the client at the same time.
(i) The provider must submit the additional information within thirty days of the department's request.
(ii) The department approves or denies the request within five business days of the receipt of the additional information.
(iii) If the provider fails to provide the additional information, the department will deny the requested service.
(8) When the department denies all or part of a request for a covered service(s) or equipment, the department sends the client and the provider written notice, within ten business days of the date the information is received, that:
(a) Includes a statement of the action the department intends to take;
(b) Includes the specific factual basis for the intended action;
(c) Includes reference to the specific WAC provision upon which the denial is based;
(d) Is in sufficient detail to enable the recipient to:
(i) Learn why the department's action was taken; and
(ii) Prepare an appropriate response.
(e) Is in sufficient detail to determine what additional or different information might be provided to challenge the department's determination;
(f) Includes the client's administrative hearing rights;
(g) Includes an explanation of the circumstances under which the denied service is continued or reinstated if a hearing is requested; and
(h) Includes examples(s) of "lesser cost alternatives" that permit the affected party to prepare an appropriate response.
(9) If an administrative hearing is requested, the department or the client may request an independent review organization (IRO) or independent medical examination (IME) to provide an opinion regarding whether the requested service or equipment is medically necessary. The department will pay for the independent assessment if the department agrees that it is necessary, or an administrative law judge orders the assessment.
[WSR 11-14-075, recodified as § 182-501-0165, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090. WSR 05-23-031, § 388-501-0165, filed 11/8/05, effective 12/9/05. Statutory Authority: RCW 74.08.090, 74.04.050, 74.09.035. WSR 00-03-035, § 388-501-0165, filed 1/12/00, effective 2/12/00. Statutory Authority: RCW 74.08.090. WSR 94-10-065 (Order 3732), § 388-501-0165, filed 5/3/94, effective 6/3/94. Formerly WAC 388-81-038.]