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WAC 182-502-0012

When 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, the applicant does not have any dispute rights within the agency.
(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.
[Statutory Authority: RCW 41.05.021, 41.05.160 and 42 C.F.R. 455.432. WSR 15-10-003, § 182-502-0012, filed 4/22/15, effective 5/23/15. Statutory Authority: RCW 41.05.021. WSR 13-17-047, § 182-502-0012, filed 8/13/13, effective 10/1/13. Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455. WSR 13-03-068, § 182-502-0012, filed 1/14/13, effective 2/14/13. WSR 11-14-075, recodified as § 182-502-0012, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0012, filed 5/9/11, effective 6/9/11.]
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