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PDFWAC 182-550-7300

OPPSPayment limitations.

(1) The medicaid agency limits payment for covered outpatient hospital services to the current published maximum allowable units of services listed in the outpatient fee schedule published on the agency's website, subject to the following limitations:
(a) To receive payment for services, providers must bill claims according to national correct coding initiative (NCCI) standards. When a unit limit for services is not stated in the outpatient fee schedule, the agency pays for services according to the program's unit limits stated in applicable WAC and published provider guides.
(b) The average resource, including units of service, are factored into the enhanced ambulatory patient group (EAPG) weight determination, and the allowable units of service for EAPGs is equal to one.
(2) The following service categories are included in the EAPG payment for significant procedure(s) on the claim and do not receive separate payments under EAPG:
(a) Services classified as the same or clinically related to the main significant procedure;
(b) Routine ancillary services;
(c) Chemotherapy services grouped as class I, class II, or minor; and
(d) Pharmacotherapy services grouped as class I, class II, or minor.
(3) The agency reduces the EAPG payment by fifty percent based on the default EAPG grouper settings for services subject to one or more of the following discounts:
(a) Multiple procedures;
(b) Repeat ancillary services; or
(c) A terminated procedure.
(4) The agency limits outpatient services billing to one claim per episode of care. If any line of the claim is denied, or a service that was provided was not stated on the initial submitted claim, the agency requires the entire claim to be adjusted.
[Statutory Authority: RCW 41.05.021, 41.05.160. WSR 18-09-022, § 182-550-7300, filed 4/11/18, effective 5/12/18. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-14-049, § 182-550-7300, filed 6/25/14, effective 7/26/14. WSR 11-14-075, recodified as § 182-550-7300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.09.500, and 74.09.530. WSR 10-08-023, § 388-550-7300, filed 3/30/10, effective 4/30/10. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-13-100, § 388-550-7300, filed 6/20/07, effective 8/1/07; WSR 04-20-061, § 388-550-7300, filed 10/1/04, effective 11/1/04.]
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