Delta Dental of Washington

Uniform Medical Plan

Kaiser Permanente of Washington

Kaiser Permanente Northwest

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.

WAC 182-543-0500 General

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.)

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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