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.

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.

WAC 182-543-0500 General.

Revised May 26, 2021

1. The federal government considers medical equipment, supplies, and appliances, which the medicaid agency refers to throughout this chapter as medical equipment, services under the medicaid program.
2. The agency pays for medical equipment, including modifications, accessories, and repairs, according to agency rules and subject to the limitations and requirements in this chapter when the medical equipment is:
   1. Medically necessary, as defined in WAC 182-500-0070;
   2. Authorized, as required within this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions and provider notices; and
   3. Billed according to this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions and provider notices.
3. 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 later than six months prior to the start of services.
4. 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.
5. Services may be ordered by:
   1. Physicians;
   2. Nurse practitioners;
   3. Clinical nurse specialists; or
   4. Physician assistants.
6. The agency requires prior authorization for covered medical equipment when the clinical criteria set forth in this chapter are not met, including the criteria associated with the expedited prior authorization process.
   1. The agency evaluates requests requiring prior authorization on a case-by-case basis to determine medical necessity as defined in WAC 182-500-0070, according to the process found in WAC 182-501-0165.
   2. Refer to WAC 182-543-7000, 182-543-7100, 182-543-7200, and 182-543-7300 for specific details regarding authorization.
7. The agency bases its determination about which medical equipment requires prior authorization (PA) or expedited prior authorization (EPA) on utilization criteria (see WAC 182-543-7100 for PA and WAC 182-543-7300 for EPA). The agency considers all of the following when establishing utilization criteria:
   1. Cost;
   2. The potential for utilization abuse;
   3. A narrow therapeutic indication; and
   4. Safety.
8. The agency evaluates a request for equipment that does not meet the definition of medical equipment or that is determined not medically necessary under the provisions of WAC 182-501-0160. When early and periodic screening, diagnosis and treatment (EPSDT) applies, the agency evaluates a noncovered service, equipment, or supply according to the process in WAC 182-501-0165 to determine if it is medically necessary, safe, effective, and not experimental (see WAC 182-543-0100 for EPSDT rules).
9. The agency may terminate a provider's participation with the agency according to WAC 182-502-0030 and 182-502-0040.
10. The agency evaluates a request for a service that meets the definition of medical equipment but has been determined to be experimental or investigational, under the provisions of WAC 182-501-0165.
11. If the agency denies a requested service, the agency notifies the client in writing that the client may request an administrative hearing under chapter 182-526 WAC. (For MCO enrollees, see WAC 182-538-110.)

WAC 182-501-0215 Wraparound with intensive services (WISe).

Revised February 25, 2023

1. Wraparound with intensive services (WISe) is a service delivery model that provides comprehensive behavioral health covered services and support to:
   1. Clients age 20 or younger with complex behavioral health needs who are eligible for coverage under WAC 182-505-0210; and
   2. Their families.
2. The authority, the managed care organizations, and the WISe provider agencies must use, continue to use, and substantially comply with the WISe quality plan (WISe QP) for the delivery of WISe. The purpose of the WISe QP is to:
   1. Provide a framework for quality management goals, objectives, processes, tools, and resources to measure the implementation and success of the WISe service delivery model; and
   2. Guide production, dissemination, and use of measures used to inform and improve WISe service delivery.
3. The WISe QP, as may be amended from time to time, is incorporated by reference and is available online at https://www.hca.wa.gov/billers-providers-partners/behavioral-health-recovery/wraparoundintensive-services-wise.

WAC 182-300-0100 Single bed certification.

Revised December 26, 2020

At the discretion of the health care authority (HCA) or HCA's designee, an exception may be granted to a facility that is not certified under chapter 246-341 WAC, for a person on an initial detention, a five-day detention pending a revocation proceeding, or a fourteen-day commitment in order to allow timely and appropriate treatment. An exception may also be granted for renewable periods of thirty days to allow a community facility to provide treatment to a person on a ninety- or one hundred eighty-day inpatient involuntary commitment order or to a person who has been revoked from a less restrictive alternative order or conditional release. For involuntarily detained or committed children, an exception may be granted to allow timely and appropriate treatment in a facility not certified under chapter 246-341 WAC, until the child's discharge from that setting to the community, or until they transfer to a bed in a children's long-term inpatient program (CLIP).

1. In the case of an adult, the behavioral health administrative services organization (BH-ASO) or a designee must submit a written request for a single bed certification to HCA or HCA's designee. In the case of a child, the facility must submit the written request to HCA or HCA's designee and provide a copy to the BH-ASO. HCA or HCA's designee must receive and approve the request in order for a facility to accept a person for timely and appropriate treatment under this section. If HCA or HCA's designee has assumed the duties assigned to a nonparticipating BH-ASO, HCA or HCA's designee may designate an entity to request a single bed certification as described in this section.
2. HCA or HCA's designee may issue a single bed certification in writing to the facility for timely and appropriate mental health treatment when the following requirements are met in each instance where such certification is sought for a person:
   1. The facility that is the site of the proposed single bed certification confirms that it is willing and able to provide directly, or by direct arrangement with other public or private agencies, timely and appropriate mental health treatment to the person for whom the single bed certification is sought; and
   2. The request for single bed certification describes why the person meets at least one of the following criteria:
      1. The person is expected to be ready for discharge from inpatient services at the facility referred to in (a) of this subsection within the next thirty days and remaining at that facility would facilitate continuity of care, consistent with the person's individual treatment needs;
      2. The person can receive appropriate mental health treatment in a residential treatment facility, as defined in WAC 246-337-005; or
      3. The person can receive appropriate mental health treatment in a hospital with a psychiatric unit, a psychiatric hospital, or a hospital that is willing and able to provide timely and appropriate mental health treatment, including a temporary health care facility that has a mental health component credentialed or approved by the department of health.
3. In order to provide timely and appropriate mental health treatment, the facility receiving the single bed certification, or the public or private agency the facility has a direct arrangement with to provide mental health treatment, must:
   1. Implement standards for administration that include written procedures to assure that a mental health professional, as defined in RCW 71.05.020, and a licensed physician, psychiatric advanced registered nurse practitioner, or physician assistant are available for consultation and communication with both the person and the direct patient care staff;
   2. Use a plan of care or treatment. The person's medical or clinical record must contain documentation that:
      1. An individualized mental health treatment plan was developed, when possible, collaboratively with the person. If the person is unwilling or unable to participate in development of the plan, documentation must be made in the record. Development of this plan may include participation of a multidisciplinary team, a mental health professional as defined in RCW 71.05.020, or collaboration with members of the person's support system as identified by the person; and
      2. A mental health professional, as defined in RCW 71.05.020, has had contact with the person at least daily for the purposes of:
         1. Observation and evaluation;
         2. Assessing whether the person is appropriate for release from involuntary commitment to accept treatment on a voluntary basis; and
   3. Have standards for administration and monitoring of medication, including psychiatric medications. A person has a right to make an informed decision regarding the use of antipsychotic medication consistent with RCW 71.05.215.
4. If a person requires medical services that are not generally available at a facility certified under chapter 246-341 WAC, or at a state psychiatric hospital, or a facility that meets the requirements of subsections (2) and (3) of this section, HCA or HCA's designee may issue a single bed certification to that facility for the person as follows:
   1. The single bed certification request must adequately describe why the person requires medical services that are not available at a facility certified under chapter 246-341 WAC, a state psychiatric hospital, or a facility that meets the requirements of subsections (2) and (3) of this section;
   2. The facility that is the site of the requested single bed certification must confirm that it is willing and able to provide the medical services; and
   3. The facility has documented that one of the following has been met:
      1. With the authorization of the facility, and consistent with any applicable facility policies and procedures, the BH-ASO assigns a mental health professional to provide the person appropriate mental health treatment at the facility, including observation and evaluation, during the period of time the person is provided medical services; or
      2. The facility provides medical services and a plan that addresses the person's mental health treatment needs until the person is medically stable and the BH-ASO or a designee identifies an appropriate facility for the person that is one of the following:
         1. The facility providing services;
         2. A facility that is certified as an evaluation and treatment (E&T) facility; or
         3. A facility that can meet the person's needs under the single bed certification criteria in this section.
   4. If a qualified medical professional determines that mental health treatment for the person is not appropriate due to medical instability, the requirements in (c) of this subsection do not apply. When the person is determined to be medically stable, the facility must ensure the requirements in (c) of this subsection are met;
   5. A person who receives services under a single bed certification under this section must be transferred to an evaluation and treatment facility, state hospital, or other placement as soon as the attending physician considers the person medically stable and a bed becomes available, unless the treating facility consents to continue treatment and continued treatment in the current setting is consistent with the best clinical interests of the person.
5. HCA or HCA's designee may make site visits at any time to verify that the terms of the single bed certification are being met. Failure to comply with any term of this exception may result in corrective action. If HCA or HCA's designee determines that the violation places people in imminent jeopardy, immediate revocation of this exception can occur.
6. The BH-ASO retains the responsibility for ensuring due process required by RCW 71.24.300 (6)(b).
7. Neither a person nor a facility has fair hearing rights as defined under chapter 182-526 WAC regarding single bed certification decisions made by HCA or HCA's designee staff.

WAC 182-521-0100 Noncountable income and resources during the COVID-19 public health emergency.

Effective December 1, 2021

1. This section describes certain types of income and resources received as a result of the COVID-19 public health emergency that the health care authority (agency) does not count as income or resources when determining apple health eligibility. This includes certain unemployment income; any Federal Pandemic Unemployment Compensation (FPUC) or Recovery Rebates authorized under the Coronavirus Aid, Relief, and Economic Security (CARES) Act; and other needs-based and disaster-related benefits authorized as a result of the COVID-19 public health emergency. The noncountable income and resources in this section are in addition to other noncountable income and resources in this title, such as those described in WAC 182-509-0320, 182-512-0860, and 182-513-1340.
2. For all apple health programs, including both modified adjusted gross income-based (MAGI) and nonmodified adjusted gross income based (non-MAGI) programs, the agency does not count as income for Apple Health determinations of eligibility or cost-sharing calculations any of the following:
   1. Federal pandemic unemployment compensation benefits of six hundred dollars per week issued for the period of March 18, 2020, through July 31, 2020;
   2.  Federal pandemic unemployment compensation benefits of three hundred dollars per week issued for the period of December 26, 2020, through September 6, 2021;
   3. Lost wages assistance unemployment compensation benefits of three hundred dollars per week issued for the period of weeks ending August 1, 2020, through September 6, 2021, due to the federal Disaster Relief Fund authorized for states to offset lost wages due to the COVID-19 pandemic, known as Lost Wage Assistance (LWA);
   4. Payments from the pandemic relief payment program as authorized by Governor Jay Inslee on December 27, 2020;
   5. Pandemic Recovery Rebates (also known as stimulus checks or economic impact payments);
   6. Needs-based and disaster-related benefits from other agencies, organizations, or tribal entities including, but not limited to:
      1. Federal Emergency Management Agency (FEMA) programs, such as FEMA COVID-19 Funeral Assistance;
      2. State programs, such as disaster cash assistance and the Washington immigrant relief fund; and
      3. Local/municipal programs, such as the city of Seattle hospitality workers relief fund and disaster relief fund for immigrants; and
   7. Pandemic-related changes to federal refundable tax credits including, but not limited to, the child tax credit, the earned income tax credit, and the child and dependent tax care credit.
3. For non-MAGI programs, the agency does not count as income any unemployment compensation received during the public health emergency.
4. The agency does not count for apple health premium calculations all income not counted for eligibility determinations for apple health programs. The agency waives monthly premiums until the first of the month following the calendar quarter in which the COVID-19 public health emergency ends.
5. All income the agency does not count for eligibility determinations for non-MAGI programs, the agency also does not count in post eligibility treatment of income (PETI) calculations for long-term services and supports. The agency does not count such income whether it is paid to the community spouse or to the spouse seeking or receiving long-term services and supports. The agency does not count such income when determining the spousal allowance or in any other part of the post-eligibility calculation process.
6. For non-MAGI programs, the agency does not count as a resource:
   1. The value of property essential for self-support (PESS) described in 20 C.F.R. 416.1222 that is subject to the requirement of producing net annual income of at least six percent of the PESS value during the period of the presidential and secretarial emergency declarations related to the COVID-19 outbreak;
   2. Pandemic recovery rebates and all other assistance described in Social Security Administration guidance; and
   3. Assistance including, but not limited to, the Temporary Expansion of the Child Tax Credit of 2021 that is not counted as income and treated under Social Security Administration guidance as not counted as resources for a period of 12 months after receipt.
7. The agency reviews cases on an individual basis and does not count as resources any disaster assistance identified as excludable under federal law for an indefinite period.
8. The agency does not count as income or resources any other payments for pandemic assistance not described in this section to the fullest extent provided for under state or federal law.
9. Any income received as unemployment compensation not described within this section is otherwise countable and the agency counts it when determining MAGI-based apple health eligibility, unless otherwise specified under state or federal law.
10. The agency does not terminate an enrollee's eligibility due to changes to an enrollee's income or resources.
11. These rules are in effect until the later of:
    1. The date the client is receiving any benefits described in this rule; or
    2. The end of the month the Secretary of the U.S. Department of Health and Human Services declares the COVID-19 public health emergency to be over.