HEALTH CARE AUTHORITY

[Filed October 11, 2019, 3:04 p.m., effective November 11, 2019]

Effective Date of Rule: Thirty-one days after filing.

Purpose: The agency is amending WAC 182-502-0012(5) and 182-502-0040(2) to allow providers to request the agency to reconsider agency decisions to deny enrollment applications, and to request the agency to reconsider terminations of a provider agreement for convenience. The reconsideration process being added to WAC 182-502-0012 is a separate process from the reconsideration process in chapter 182-526 WAC and separate from the dispute resolution process in WAC 182-502-0050. The agency is amending WAC 182-502-0060 to remove subsections (1) and (2) that prohibit providers from reapplying for participation after the agency denies enrollment or removes a provider from participation. The agency has determined that the rules need to be amended to allow for due process and for reporting purposes.

Citation of Rules Affected by this Order: Amending WAC 182-502-0012, 182-502-0040, and 182-502-0060.

Statutory Authority for Adoption: RCW 41.05.021, 41.05.160.

Adopted under notice filed as WSR 19-18-100 on September 4, 2019.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 3, Repealed 0.

Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 3, Repealed 0.

Date Adopted: October 11, 2019.

AMENDATORY SECTION(Amending WSR 15-10-003, filed 4/22/15, effective 5/23/15)

WAC 182-502-0012When the medicaid agency does not enroll.

(1) The medicaid agency does not enroll a health care professional, health care entity, supplier, or contractor of service for reasons which include, but are not limited to, the following:

(a) The agency determines that:

(i) There is a quality of care issue with significant risk factors that may endanger client health, or safety, or both (see WAC 182-502-0030 (1)(a)); or

(ii) There are risk factors that affect the credibility, honesty, or veracity of the health care practitioner (see WAC 182-502-0030 (1)(b)).

(b) The health care professional, health care entity, supplier or contractor of service:

(i) Is excluded from participation in medicare, medicaid or any other federally funded health care program;

(ii) Has a current formal or informal pending disciplinary action, statement of charges, or the equivalent from any state or federal professional disciplinary body at the time of initial application;

(iii) Has a suspended, terminated, revoked, or surrendered professional license as defined under chapter 18.130 RCW;

(iv) Has a restricted, suspended, terminated, revoked, or surrendered professional license in any state;

(v) Is noncompliant with the department of health or other state health care agency's stipulation of informal disposition, agreed order, final order, or similar licensure restriction;

(vi) Is suspended or terminated by any agency within the state of Washington that arranges for the provision of health care;

(vii) Fails a background check, including a fingerprint-based criminal background check, performed by the agency. See WAC 182-502-0014 and 182-502-0016; or

(viii) Does not have sufficient liability insurance according to WAC 182-502-0016 for the scope of practice, to the extent the health care professional, health care entity, supplier or contractor of service is not covered by the Federal Tort Claims Act, including related rules and regulations.

(c) A site visit under 42 C.F.R. 455.432 reveals that the provider has failed to comply with a state or federal requirement.

(2) The agency may not pay for any health care service, drug, supply or equipment prescribed or ordered by a health care professional, health care entity, supplier or contractor of service whose application for a core provider agreement (CPA) has been denied or terminated.

(3) The agency may not pay for any health care service, drug, supply, or equipment prescribed or ordered by a health care professional, health care entity, supplier or contractor of service who does not have a current CPA with the agency when the agency determines there is a potential danger to a client's health and/or safety.

(4) Nothing in this chapter precludes the agency from entering into other forms of written agreements with a health care professional, health care entity, supplier or contractor of service.

(5) If the agency denies an enrollment application under this section, the applicant ((does not have any dispute rights within the agency))may request that the agency reconsider the denial.

(a) The agency's decision at reconsideration is the agency's final decision.

(b) The agency reconsiders the applicant according to the process and guidelines outlined in subsections (1) through (4) of this section.

(c) The reconsideration process in this section is unrelated to the reconsideration process described in chapter 182-526 WAC.

(6) Under 42 C.F.R. 455.470, the agency:

(a) Will impose a temporary moratorium on enrollment when directed by CMS; or

(b) May initiate and impose a temporary moratorium on enrollment when approved by CMS.

AMENDATORY SECTION(Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)

WAC 182-502-0040Termination of a provider agreement—For convenience.

(1) Either the ((department))medicaid agency or the provider may terminate the provider's participation with the ((department))agency for convenience with thirty calendar days written notice served upon the other party in a manner which provides proof of receipt or proof of valid attempt to deliver.

(2) Terminations for convenience are not eligible for the dispute resolution process described in WAC ((388-502-0050))182-502-0050. Terminations for convenience are eligible for reconsideration as described in WAC 182-502-0012.

(3) If a provider is terminated for convenience, the ((department))agency pays for authorized services provided up to the date of termination only.

AMENDATORY SECTION(Amending WSR 15-15-050, filed 7/9/15, effective 8/9/15)

WAC 182-502-0060Reapplying for participation.

(((1) Providers who are denied enrollment or removed from participation are not eligible to reapply for participation with the medicaid agency for five years from the date of denial or termination.

(2) Providers who are denied enrollment or removed from participation more than once are not eligible to reapply for participation with the agency.

(3))) A provider who is terminated solely under WAC 182-502-0030(3) is eligible for immediate reapplication with the medicaid agency if the provider is not a full or partial owner of a terminated group practice.