WAC 182-501-0200 Third-party resources.

Effective August 6, 2021

1. The medicaid agency requires a provider to seek timely reimbursement from a third party when a client has available third-party resources, except as described under subsections (2) and (3) of this section.
2. The agency pays for medical services and seeks reimbursement from a liable third party when the claim is for preventive pediatric services as covered under the early and periodic screening, diagnosis and treatment (EPSDT) program.
3. The agency pays for medical services and seeks reimbursement from any liable third party when both of the following apply:
   1. The provider submits to the agency documentation of billing the third party and the provider has not received payment after one hundred days from the date of services; and
   2. The claim is for a covered service provided to a client on whose behalf the office of support enforcement is enforcing a noncustodial parent to pay support. For the purpose of this section, "is enforcing" means the noncustodial parent either:
      1. Is not complying with an existing court order; or
      2. Received payment directly from the third party and did not pay for the medical services.
4. The provider may not bill the agency or the client for a covered service when a third party pays a provider the same amount as or more than the agency rate.
5. When the provider receives payment from a third party after receiving reimbursement from the agency, the provider must refund to the agency the amount of the:
   1. Third-party payment when the payment is less than the agency's maximum allowable rate; or
   2. Agency payment when the third-party payment is equal to or more than the agency's maximum allowable rate.
6. The agency does not pay for medical services if third-party benefits are available to pay for the client's medical services when the provider bills the agency, except under subsections (2) and (3) of this section.
7. The client is liable for charges for covered medical services that would be paid by the third-party payment when the client either:
   1. Receives direct third-party reimbursement for the services; or
   2. Fails to execute legal signatures on insurance forms, billing documents, or other forms necessary to receive insurance payments for services rendered. See WAC 182-503-0540 for assignment of rights.
8. The agency considers an adoptive family to be a third-party resource for the medical expenses of the birth mother and child only when there is a written contract between the adopting family and either the birth mother, the attorney, the provider, or the adoption service. The contract must specify that the adopting family will pay for the medical care associated with the pregnancy.
9. A provider cannot refuse to furnish covered services to a client because of a third-party's potential liability for the services.
10. For third-party liability on personal injury litigation claims, the agency or managed care organization (MCO) is responsible for providing medical services under WAC 182-501-0100.

WAC 182-554-500 Covered orally administered enteral nutrition products, equipment and related supplies - Clients age twenty and younger only.

Effective May 1, 2017

1. Subject to the prior authorization requirements and limitations in this section, and in the Enteral Nutrition Program Billing Guide, the agency covers orally administered enteral nutrition products for clients age twenty and younger.
2. The agency's enteral nutrition program is not a food benefit. All clients under age five who qualify for supplemental nutrition from the women, infants, and children (WIC) nutrition program must receive products and formulas directly from that program. The agency may cover orally administered enteral nutrition products for a client under age five if the client has a WIC information form that verifies:
   1. The client is not eligible for the WIC program;
   2. The client is eligible for the WIC program, but the client's need for an oral enteral nutrition product or formula exceeds the amount allowed by WIC rules; or
   3. The client is eligible for the WIC program, but a medically necessary product or formula is not available through the WIC program.
3. With expedited prior authorization, the agency covers orally administered enteral nutrition products for a one-time, initial one-month supply if the client:
   1. Has or is at risk of growth or nutrient deficits due to a condition that prevents the client from meeting their needs using food, over-the-counter nutrition products, standard infant formula, or standard toddler formula; and
   2. Has completed the agency's enteral nutrition products prescription form (HCA 13-961).
4. With prior authorization (PA), the agency covers a monthly supply of orally administered enteral nutrition products if the client:
   1. Has or is at risk of growth or nutrient deficits due to a condition that prevents the client from meeting their needs using food, over-the-counter nutrition products, standard infant formula, or standard toddler formula;
   2. Has a valid prescription that states the product is medically necessary as defined in WAC 182-500-0070; and
   3. Has a nutrition assessment from a registered dietitian (RD) that includes all of the following:
      1. Evaluation of the client's nutritional status, including growth and nutrient analysis;
      2. An explanation about why the product is medically necessary as defined in WAC 182-500-0070;
      3. A nutrition care plan that monitors the client's nutrition status, and includes plans for transitioning the client to food or food products, if possible; and
      4. Recommendations, as necessary, for the primary care provider to refer the client to other health care providers (for example, gastrointestinal specialists, allergists, speech therapists, occupational therapists, applied behavioral analysis providers, and mental health providers) who will address the client's growth or nutrient deficits as described in (a) of this subsection, and facilitate the client's transition to food or food products.
5. If a client requires orally administered enteral nutrition products for longer than one month, the client must continue to meet criteria in subsection (4) of this section and receive periodic reevaluations from an RD. Periodic reevaluations:
   1. Must be performed at least three times a year for a client age three or younger;
   2. Must be performed at least two times a year for a client older than age three; and
   3. May be performed face-to-face, or by medical record and growth data review and phone contact with the client or the client's caregiver.
6. If a client requires orally administered enteral nutrition products for longer than one month, the DME or pharmacy provider must obtain PA from the agency. The request for PA must include all of the following:
   1. Documentation of the client's diagnosis that supports the client's need for the orally administered enteral nutrition product;
   2. The client's nutrition care plan, which must monitor the client's nutrition status, and transition the client to food or food products, if possible, or document why the client cannot transition to food or food products;
   3. Updates to the client's nutrition care plan resulting from subsequent reevaluations;
   4. Updates to the client's growth chart;
   5. Documentation that shows through regular follow up and weight checks how the prescribed product is treating the client's growth or nutrient deficits, or is necessary to maintain the client's growth or nutrient status;
   6. Referrals, if necessary, to other health care providers (for example, gastrointestinal specialists, allergists, speech therapists, occupational therapists, applied behavioral analysis providers, and mental health providers) and show communication of recommendations and treatment plans for the client; and
   7. Documentation of any communication the treating provider has had with other providers, such as those in subsection (4)(c)(iv) of this section, directly or indirectly treating the client's growth or nutrient deficits while the client is receiving orally administered enteral nutrition products.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page