(1) The department:
(a) Pays for the admission of an eligible medical assistance client to a hospital only when the client's attending physician orders admission and when the admission and treatment provided:
(i) Are covered according to WAC 388-501-0050
(ii) Are medically necessary as defined in WAC 388-500-0005
(iii) Are determined according to WAC 388-501-0165
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 388-502-0020
(3) The department:
(a) Pays for a hospital covered service provided to an eligible medical assistance client enrolled in a department managed care organization (MCO) plan, under the fee-for-service program if the service is excluded from the MCO's capitation contract with the department and meets prior authorization requirements. (See WAC 388-550-2600
for inpatient psychiatric services.)
(b) Does not pay for nonemergency services provided to a medical assistance client from a nonparticipating hospital in a selective contracting area (SCA) unless exclusions in WAC 388-550-4600
apply. The department's selective contracting program and selective contracting payment limitations end for hospital claims with dates of admission before July 1, 2007.
(4) The department 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.
See WAC 388-533-0701
(5) The department 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 department to perform these services and the services are approved by the division of alcohol and substance abuse (DASA); or
(b) In an acute hospital and all of the following criteria are met:
(i) The hospital does not have a detoxification specific provider agreement with DASA;
(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 regional support network (RSN) or a mental health division (MHD) 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 department's chemical-using pregnant (CUP) women program; and
(vii) The client's principal diagnosis meets the department's medical inpatient detoxification criteria listed in the department's published billing instructions.
(6) The department covers medically necessary dental-related services provided to an eligible client in a hospital-based dental clinic when the services:
(a) Are provided in accordance with chapter 388-535
(b) Are billed on the American Dental Association (ADA) or health care financing administration (HCFA) claim form.
(7) The department 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 in accordance with chapter 388-535
(b) The covered dental-related services are billed on a UB claim form; and
(c) At least on of the following is true:
(i) The dental-related service(s) is provided to an eligible medical assistance 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 department.
(8) For inpatient voluntary or involuntary psychiatric admissions, see WAC 388-550-2600
[11-14-075, recodified as § 182-550-1100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500. 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. 01-16-142, § 388-550-1100, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW 74.08.090. 01-02-075, § 388-550-1100, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-1100, filed 12/18/97, effective 1/18/98.]