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Chapter 296-23A WAC

Last Update: 4/3/07

HOSPITALS

WAC Sections

PART 1 - GENERAL INFORMATION
Where can I find general information and rules pertaining to the care of workers?
When will the department or self-insurer pay for hospital services?
What services are subject to review by the department or self-insurer?
How does the department establish hospital payment rates?
How can interested persons request advance notice of changes to hospital payment rates, methods and policies?
PART 1.1 - SUBMITTING BILLS
How must hospitals submit bills for hospital services?
How must hospitals submit charges for ambulance and professional services?
How must hospitals bill the department or self-insurer for preadmission services?
PART 1.2 - SUPPORTING DOCUMENTATION REQUIREMENTS
What supporting documentation must hospitals send for hospital services?
Where must hospitals send supporting documentation for hospital services for state fund claims?
When must providers using electronic medium submit supporting documentation?
PART 2 - PAYMENT METHODS FOR HOSPITAL SERVICES
How does the department pay for hospital inpatient services?
How do self-insurers pay for hospital inpatient services?
How does the department pay for hospital outpatient services?
How does the self-insurer pay for hospital outpatient services?
How does the department or self-insurer pay out-of-state hospitals for hospital services?
How does the department define and pay a new hospital?
Does a change in hospital ownership affect a hospital's payment rate?
PART 2.1 - PERCENT OF ALLOWED CHARGES (POAC)
PAYMENT METHODS AND POLICIES
When do percent of allowed charges (POAC) payment factors apply?
What is the method for calculating percent of allowed charges (POAC) factors?
PART 2.2 - PER DIEM PAYMENT METHODS AND POLICIES
When do per diem rates apply?
What is the method for calculating per diem rates?
PART 2.3 - DIAGNOSIS-RELATED-GROUP PAYMENT METHODS AND POLICIES
What is a "diagnosis-related-group" payment system?
How does the department calculate diagnosis-related-group (DRG) relative weights?
How does the department determine the base price for hospital services paid using per case rates?
How does the department calculate a hospital specific case-mix adjusted average cost per case?
How does the department calculate the base price for DRG hospitals, except major teaching hospitals?
What cases does the department exclude from base price calculations?
How does the department calculate the diagnosis-related-group (DRG) per case payment rate for a particular hospital?
Which exclusions and exceptions apply to diagnosis-related-group (DRG) payments for hospital services?
Which hospitals does the department exclude from diagnosis-related-group (DRG) payments?
Which hospital services does the department include in diagnosis-related-group (DRG) rates?
When does a case qualify for high outlier status?
How does the department pay for high outlier cases?
How does a case qualify for low outlier status?
How does the department pay for low outlier cases?
Under what circumstances will the department pay for interim bills?
How does the department define and pay for hospital readmissions?
How does the department define a transfer case?
How does the department pay a transferring hospital for a transfer case?
How does the department pay the receiving hospital for a transfer case?
PART 3 - REQUESTING A HOSPITAL RATE ADJUSTMENT
How can a hospital request a rate adjustment?
Where must hospitals submit requests for rate adjustments?
What action will the department take upon receipt of a request for a rate adjustment?
PART 4 - AMBULATORY PAYMENT CLASSIFICATION PAYMENT METHODS AND POLICIES
What is the "ambulatory payment classification" (APC) payment system?
Definitions.
How does the department calculate the hospital-specific per APC rate used for paying outpatient services under the outpatient prospective payment system (OPPS)?
How does the department determine the APC relative weights?
How does the department calculate payments for covered outpatient services through the outpatient prospective payment system (OPPS)?
What exclusions and exceptions apply to ambulatory-payment-classification (APC) payments for hospital services?
How will excluded outpatient services and hospitals be paid?
What information needs to be submitted for the hospital to be paid for outpatient services?