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182-538-095  <<  182-538-096 >>   182-538-100

PDFWAC 182-538-096

Scope of service for PCCM enrollees.

(1) An enrollee is entitled to timely access to covered services that are medically necessary.
(2) A primary care case management (PCCM) enrollee is eligible for the scope of services that are covered based on the enrollee's apple health eligibility program. See WAC 182-501-0060 and 182-501-0065 for categories of services that are covered and program rules for specific services that are covered.
(3) The agency covers services through the fee-for-service system for enrollees with a primary care case management (PCCM) provider.
(a) The PCCM provider must either provide the covered services or refer the enrollee to other providers who are contracted with the agency for covered services, except for emergency services.
(b) The PCCM provider is responsible for explaining to the enrollee how to obtain the services for which the PCCM provider is referring the enrollee.
(c) Services that require PCCM provider referral are described in the PCCM contract.
(d) The agency sends each enrollee written information about covered services when the client enrolls in managed care and when there is a change in covered services. This information describes covered services, which services are covered by the agency, and how to access services through the PCCM provider.
(4) The agency will not authorize or pay for the following services:
(a) Services that are not medically necessary as defined in WAC 182-500-0070.
(b) Services not included in the scope of covered services for the client's apple health eligibility program.
(c) Services received in a hospital emergency department for nonemergency medical conditions, other than a screening exam as described in WAC 182-538-100(3).
[Statutory Authority: RCW 41.05.021, 41.05.160, 2019 c 325, 2014 c 225, and 2018 c 201. WSR 19-24-063, § 182-538-096, filed 11/27/19, effective 1/1/20. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-24-098, § 182-538-096, filed 12/1/15, effective 1/1/16.]
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