(1) The medicaid agency:
(a) Pays for an eligible Washington apple health (WAH) client's admission to a hospital only when the client's attending physician orders admission and when the admission and treatment provided:
(ii) Are medically necessary as defined in WAC 182-500-0070
(iii) Are determined according to WAC 182-501-0165
when prior authorization is required;
(iv) Are authorized when required under this chapter; and
(v) Meet applicable state and federal requirements.
(b) For hospital admissions, defines "attending physician" as the client's primary care provider, or the primary provider of care to the client at the time of admission.
(2) Medical record documentation of hospital services must meet the requirements in WAC 182-502-0020
(3) The agency:
(a) Pays for a hospital covered service provided to an eligible WAH client enrolled in an agency-contracted managed care organization (MCO) plan, under the fee-for-service program if the service is excluded from the MCO's capitation contract with the agency and meets prior authorization requirements. (See WAC 182-550-2600
for inpatient psychiatric services.)
(b) Does not pay for nonemergency services provided to a WAH client from a nonparticipating hospital in a selective contracting area (SCA) unless exclusions in WAC 182-550-4700
apply. The agency's selective contracting program and selective contracting payment limitations end for hospital claims with dates of admission before July 1, 2007.
(4) The agency pays up to twenty-six days of inpatient hospital care for hospital-based detoxification, medical stabilization, and drug treatment for chemical dependent pregnant clients eligible under the chemical-using pregnant (CUP) women program.
(5) The agency pays for inpatient hospital detoxification of acute alcohol or other drug intoxication when the services are provided to an eligible client:
(a) In a detoxification unit in a hospital that has a detoxification provider agreement with the agency to perform these services and the services are approved by the division of behavioral health and recovery (DBHR) within the department of social and health services (DSHS); or
(b) In an acute hospital and all the following criteria are met:
(i) The hospital does not have a detoxification specific provider agreement with DBHR;
(ii) The hospital provides the care in a medical unit;
(iii) Nonhospital based detoxification is not medically appropriate for the client;
(iv) The client does not require medically necessary inpatient psychiatric care and it is determined that an approval from a behavioral health organization (BHO) or a DBHR designee as an inpatient stay is not indicated;
(v) The client's stay qualifies as an inpatient stay;
(vi) The client is not participating in the agency's chemical-using pregnant (CUP) women program; and
(vii) The client's principal diagnosis meets the agency's medical inpatient detoxification criteria listed in the agency's published billing instructions.
(6) The agency covers medically necessary dental-related services provided to an eligible client in a hospital-based dental clinic when the services:
(a) Are provided under chapter 182-535
(b) Are billed on the American Dental Association (ADA) or health care financing administration (HCFA) claim form.
(7) The agency pays a hospital for covered dental-related services, including oral and maxillofacial surgeries, that are provided in the hospital's operating room, when:
(a) The covered dental-related services are medically necessary and provided under chapter 182-535
(b) The covered dental-related services are billed on a UB claim form; and
(c) At least one of the following is true:
(i) The dental-related service(s) is provided to an eligible WAH client on an emergency basis;
(ii) The client is eligible under the division of developmental disability program;
(iii) The client is age eight or younger; or
(iv) The dental service is prior authorized by the agency.
(8) For inpatient voluntary or involuntary psychiatric admissions, see WAC 182-550-2600.
[Statutory Authority: RCW 41.05.021
, 2014 c 225. WSR 16-06-053, § 182-550-1100, filed 2/24/16, effective 4/1/16. Statutory Authority: RCW 41.05.021
. WSR 15-18-065, § 182-550-1100, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-1100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090
. WSR 07-14-053, § 388-550-1100, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090
and 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, .11303, and .2652. WSR 01-16-142, § 388-550-1100, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW 74.08.090
. WSR 01-02-075, § 388-550-1100, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090
, [74.09.]500, [74.09.]530 and 43.20B.020
. WSR 98-01-124, § 388-550-1100, filed 12/18/97, effective 1/18/98.]