(1) The department 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) The department 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) The department pays for medical services and seeks reimbursement from any liable third party when both of the following apply:
(a) The provider submits to the department 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 the department or the client for a covered service when a third party pays a provider the same amount as or more than the department rate.
(5) When the provider receives payment from the third party after receiving reimbursement from the department, the provider must refund to the department the amount of the:
(a) Third-party payment when the payment is less than the department's maximum allowable rate; or
(b) The department payment when the third-party payment is equal to or greater than the department's maximum allowable rate.
(6) The department 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 the department, 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) The department 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, the department is responsible for providing medical services as described under WAC 388-501-0100
[11-14-075, recodified as § 182-501-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. 10-19-057, § 388-501-0200, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.04.050, 74.08.090. 00-11-141, § 388-501-0200, filed 5/23/00, effective 6/23/00; 00-01-088, § 388-501-0200, filed 12/14/99, effective 1/14/00.]