00349: 3M Inpatient Grouper Issue
Discovery log number
00349
Discovery description

Due to a system issue involving the inpatient grouping software that is still being tracked, some inpatient claims received by HCA may either improperly fail to group to a DRG, causing a denial, or in a smaller number of cases, group to an incorrect DRG, which may cause some denials or pricing changes. The issue will be resolved as quickly as possible.

In most cases involving this issue, providers will see inpatient claims deny for failure to group to a DRG. In a minority of cases, there may be some claims which group to an incorrect DRG.

Date reported
ETA
Provider impact
Phase 1
Workaround
Follow established processes for checking into claims denials through customer service phone or email. Alternatively, the user may attempt to adjust claims themselves as most claims group correctly on the second attempt.

Value-based purchasing (VBP)

The Health Care Authority (HCA) is the largest health care purchaser in the state. We purchase health care for almost 3 million Washington residents through our Apple Health (Medicaid), Public Employees Benefits Board (PEBB), and School Employees Benefits Board (SEBB) programs.

HCA is leading the effort to transform health care, helping ensure Washington residents have access to better health and better care at a lower cost. Our goal is to achieve a healthier Washington by containing costs while improving outcomes, patient and provider experience, and equity through innovative VBP strategies.

We call this effort “paying for health and value.” One way we achieve this is through value-based purchasing (VBP).

What's VBP?

VBP is a range of strategies intended to contain costs while improving outcomes by tying health care payment to care quality. VBP rewards providers for health care quality, incentivizing them to focus on primary and preventive care. It also holds plans and providers accountable for providing high-quality, high-value care and a satisfying patient experience.

What's fee-for-service?

Traditional health care payment is called fee-for-service (FFS) payment. In FFS contracts, providers are paid for each patient they see and each service they provide. This means that providers receive the same pay whether or not the patient improves and regardless of the appropriateness of care. FFS payment also incentivizes seeing a high volume of patients and providing more expensive specialty services.

VBP strategies take the place of traditional FFS payment. VBP comes in many forms, and HCA uses a variety of tools and approaches to promote VBP.

Goals

We achieve a healthier Washington by:

  • Aligning Apple Health, PEBB, SEBB, and other programs to a VBP philosophy.
  • Holding health care plan partners and delivery system networks accountable for providing quality and value.
  • Exercising significant oversight and quality assurance over contracting partners and implementing corrective action, if necessary.

News and updates

2025

Date Title
June 26 2025 Paying for Value survey now open
2024
Date Title
December 23 2024 Paying for Value survey results are in
August 1 Health care providers: there’s still time to fill out the HCA 2024 Paying for Value survey!
July 1 Health care providers, we want to hear from you
July 1 Calling all health plans: 2024 Paying for Value survey now open
March 6 2023 Paying for Value survey results are in
Pictogram of person with thought bubble

How do I…

What should employees do if they have questions?

The SEBB Program is directing employees to contact their payroll or benefits office.

How can BAs get help with employee questions?

Call SEBB Outreach and Training at 1-800-700-1555 or send a question via HCA Support. This phone number and email address are for benefits administrators only. Do not give it to employees.

Life insurance

Willamette Dental Group of Washington, Inc.

Delta Dental of Washington

For Medicare retirees and COBRA subscribers

WAC 182-530-5000 Billing requirements - Pharmacy claim payment

WAC 182-530-5000 Billing requirements—Pharmacy claim payment.

Revised March 14, 2021

  1. When billing the medicaid agency for pharmacy services, providers must:
    1. Use the appropriate agency claim form or electronic billing specifications;
    2. Include the actual eleven-digit national drug code (NDC) number of the product dispensed from a rebate eligible manufacturer;
    3. Bill the agency using metric decimal quantities which is the National Council for Prescription Drug Programs (NCPDP) billing unit standard;
    4. Meet the general provider documentation and record retention requirements in WAC 182-502-0020; and
    5. Maintain proof of delivery receipts.
      1. When a provider delivers an item directly to the client or the client's authorized representative, the provider must be able to furnish proof of delivery, including the signature of either the client or the provider, the client's name, and a detailed description of the item or items delivered.
      2. When a provider mails an item to the client, the provider must be able to furnish proof of delivery including a mail log.
      3. When a provider uses a delivery or shipping service to deliver items, the provider must be able to furnish proof of delivery and it must:
        1. Include the delivery service tracking slip with the client's name or a reference to the client's package or packages; the delivery service package identification number; and the delivery address.
        2. Include the supplier's shipping invoice, with the client's name; the shipping service package identification number; and a detailed description.
      4. Make proof of delivery receipts available to the agency upon request.
  2. When billing drugs under the expedited authorization process, providers must insert the authorization number, which includes the corresponding criteria code or codes in the appropriate data field on the drug claim.
  3. Pharmacy services for clients on restriction under WAC 182-501-0135 must be prescribed by the client's primary care provider and are paid only to the client's primary pharmacy, except in cases of:
    1. Emergency;
    2. Family planning services; or
    3. Services properly referred from the client's assigned pharmacy or physician/ARNP.

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.

WAC 182-551-2040 Face-to-face encounter requirements

WAC 182-551-2040 Face-to-face encounter requirements.

Revised March 26, 2021

  1. The face-to-face encounter requirements of this section may be met using telemedicine or telehealth services. See WAC 182-551-2125.
  2. The medicaid agency pays for home health services provided under this chapter only when the face-to-face encounter requirements in this section are met.
  3. For initiation of home health services, with the exception of medical equipment under WAC 182-551-2122, the face-to-face encounter must be related to the primary reason the client requires home health services and must occur within ninety days before or with-in the thirty days after the start of the services.
  4. For the initiation of medical equipment under WAC 182-551-2122, the face-to-face encounter must be related to the primary reason the client requires medical equipment and must occur no more than six months before the start of services.
  5. The face-to-face encounter may be conducted by:
    1. A physician;
    2. A nurse practitioner;
    3. A clinical nurse specialist;
    4. A certified nurse midwife under 42 C.F.R. 440.70 when furnished by a home health agency that meets the conditions of participation for medicare;
    5. A physician assistant; or
    6. The attending acute, or post-acute physician, for beneficiaries admitted to home health immediately after an acute or post-acute stay.
  6. Services may be ordered by:
    1. Physicians;
    2. Nurse practitioners;
    3. Clinical nurse specialists; or
    4. Physician assistants.
  7. For all home health services except medical equipment under WAC 182-551-2122, the physician, nurse practitioner, clinical nurse specialist, or physician assistant responsible for ordering the services must:
    1. Document that the face-to-face encounter, which is related to the primary reason the client requires home health services, occurred within the required time frames described in subsection (3) of this section prior to the start of home health services; and
    2. Indicate the practitioner who conducted the encounter, and the date of the encounter.
  8. For medical equipment under WAC 182-551-2122, except as provided in (b) of this subsection, an ordering physician, nurse practitioner, clinical nurse specialist, physician assistant, or the attending physician when a client is discharged from an acute hospital stay, must:
    1. Document that the face-to-face encounter, which is related to the primary reason the client requires home health services, occurred within the required time frames described in subsection (4) of this section prior to the start of home health services; and
    2. Indicate the practitioner who conducted the encounter, and the date of the encounter.

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.

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