| Washington State Health Care Authority

WAC 182-503-0070 Washington apple health (WAH)-- When coverage begins.

WAC 182-503-0070 Washington apple health (WAH)-- When coverage begins.

Effective August 29, 2014.

Your Washington apple health (WAH) coverage starts on the first day of the month you applied for and we decided you are eligible to receive coverage, unless one of the exceptions in subsection (4) of this section applies to you.
Sometimes we can start your coverage up to three months before the month you applied (see WAC 182-504-0005).
If you are confined or incarcerated as described in WAC 182-503-0010, your coverage cannot start before the day you are discharged, except when:
1. You are hospitalized during your confinement; and
2. The hospital requires you to stay overnight.
Your WAH coverage may not begin on the first day of the month if:
1. Subsection (3) of this section applies to you. In that case, your coverage would start on the first day of your hospital stay;
2. You must meet a medically needy spenddown liability (see WAC 182-519-0110). In that case, your coverage would start on the day your spenddown is met; or
3. You are eligible under the WAH alien emergency medical program (see WAC 182-507-0115). In that case, your coverage would start on the day your emergent hospital stay begins.
For long-term care, the date your services start is described in WAC 388-106-0045.

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 182-503-0050 Verification of eligibility factors.

WAC 182-503-0050 Verification of eligibility factors.

Effective November 3, 2019

General rules.
1. We may verify the information we use to determine, redetermine, or terminate your apple health eligibility.
2. We verify the eligibility factors listed in WAC 182-503-0505(3).
3. Before we ask you to provide records to verify an eligibility factor, we use information available from state databases, including data from the department of social and health services and the department of employment security, federal databases, or commercially available databases to verify the eligibility factor.
4. We may require information from third parties, such as employers, landlords, and insurance companies, to verify an eligibility factor if the information we received:
  1. Cannot be verified through available data sources;
  2. Did not verify an eligibility factor; or
  3. Is contradictory, confusing, or outdated.
5. We do not require you to submit a record unless it is necessary to determine or redetermine your eligibility.
6. If you can obtain verification within three business days and we determine the verification is sufficient to confirm an eligibility factor, we base our initial eligibility decision upon that record.
7. If we are unable to verify eligibility as described in (f) of this subsection, then we may consider third-party sources.
8. If a fee is required to obtain a necessary record, we pay the fee directly to the holder of the record.
9. We do not deny or delay your application if you failed to provide information to verify an eligibility factor in a particular type or form.
10. Except for eligibility factors listed in WAC 182-503-0505 (3)(c) and (d), we accept alternative forms of verification. If you give us a reasonable explanation that confirms your eligibility, we may not require additional documentation.
11. Once we verify an eligibility factor that will not change, we may not require additional verification. Examples include:
  1. U.S. citizenship;
  2. Family relationships by birth;
  3. Social Security numbers; and
  4. Dates of birth, death, marriage, dissolution of marriage, or legal separation.
12. If we cannot verify your immigration status and you are otherwise eligible for Washington apple health, we approve coverage and give additional time as needed to verify your immigration status.
Submission timelines.
1. We allow at least ten calendar days for you to submit requested information.
2. If you request more time to provide information, we allow the time requested.
3. If the tenth day falls on a weekend or a legal holiday as described in RCW 1.16.050, the due date is the next business day.
4. We do not deny or terminate your eligibility when we give you more time to provide information.
5. If we do not receive your information by the due date, we make a determination based on all the information available.
Notice requirements.
1. When we need more information from you to determine your eligibility for apple health coverage, we send all notices according to the requirements of WAC 182-518-0015.
2. If we cannot determine you are eligible, we send you a denial or termination notice including information on when we reconsider a denied application under WAC 182-503-0080.
Equal access and limited-English proficiency services. If you are eligible for equal access services under WAC 182-503-0120 or limited-English proficiency services under WAC 182-503-0110, we provide legally sufficient support services.
Eligibility factors for nonmodified adjusted gross income (MAGI)-based programs. If you apply for a non-MAGI program under WAC 182-503-0510(3), we verify the factors in WAC 182-503-0505(3). In addition, we verify:
1. Household composition, if spousal or dependent deeming under chapter 182-512 WAC or spousal or dependent allowance under chapters 182-513 and 182-515 WAC applies;
2. Income and income deductions;
3. Resources, including:
  1. Trusts, annuities, life estates and promissory notes under chapter 182-516 WAC;
  2. Real property transactions; and
  3. Financial records, as defined in WAC 182-503-0055, held by financial institutions.
4. Medical expenses required to meet any spenddown liability under WAC 182-519-0110;
5. All post-eligibility deductions used to determine cost of care for clients eligible for long-term services and supports under chapters 182-513 and 182-515 WAC;
6. Transfers of assets under chapter 182-513 WAC and WAC 182-503-0055 when the program is subject to transfer of assets limitations;
7. Shelter costs for long-term care cases where spousal and dependent allowances apply;
8. Blindness or disability, if you claim either; and
9. Social Security number for a community spouse if needed when you apply for long-term care.
Verification for MAGI-based programs.
1. After we approve your coverage based on your self-attestation, we may conduct a post-eligibility review to verify your self-attested information.
2. When conducting a post-eligibility review, we attempt to verify eligibility factors using your self-attested information available to us through state, federal, and commercially available data sources, or other third parties, before requiring you to provide information.
3. You may be required to provide additional information if:
  1. We cannot verify an eligibility factor through other data sources listed in subsection (b) of this section; or
  2. The information received from the data source is not reasonably compatible with your self-attestation.
Reapplication following post-eligibility review. If your eligibility for MAGI-based apple health terminates because of a post-eligibility review and you reapply, we may request verification of eligibility factors prior to determining eligibility.

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 182-503-0010 Washington apple health -- Who may apply.

WAC 182-503-0010 Washington apple health -- Who may apply.

Effective January 16, 2020.

You may apply for Washington apple health for yourself.
You may apply for apple health for another person if you are:
1. A legal guardian;
2. An authorized representative (as described in WAC 182-503-0130);
3. A parent or caretaker relative of a child age eighteen or younger;
4. A tax filer applying for a tax dependent;
5. A spouse; or
6. A person applying for someone who is unable to apply on their own due to a medical condition and who is in need of long-term care services.
If you reside in an institution of mental diseases (as defined in WAC 182-500-0050(1)) or a public institution (as defined in WAC 182-500-0050(4)), including a Washington state department of corrections facility, city, tribal, or county jail, or secure community transition facility or total confinement facility (as defined in RCW 71.09.020), you, your representative, or the facility may apply for you to get the apple health coverage for which you are determined eligible.
You are automatically enrolled in apple health and do not need to submit an application if you are a:
1. Supplemental security income (SSI) recipient;
2. Person deemed to be an SSI recipient under 1619(b) of the SSA;
3. Newborn as described in WAC 182-505-0210; or
4. Child in foster care placement as described in WAC 182-505-0211.
You are the primary applicant on an application if you complete and sign the application on behalf of your household.
If you are an SSI recipient, then you, your authorized representative as defined in WAC 182-500-0010, or another person applying on your behalf as described in subsection (2) of this section, must turn in a signed application to apply for long-term care services as described in WAC 182-513-1315.

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 182-503-0001 Insurance affordability programs -- Overview.

WAC 182-503-0001 Insurance affordability programs -- Overview.

Effective August 29, 2014.

For the purposes of this chapter, "we" or "us" refers to the agency or its designee and "you" refers to the applicant for, or recipient of, health care coverage.
A person may apply for all of the insurance affordability programs offered through the health care authority (HCA) or the Washington Healthplanfinder (as defined in WAC 182-500-0015):
1. Washington apple health (WAH) programs (defined in WAC 182-500-0120). WAH includes medicaid programs (defined in WAC 182-500-0070), the children's health insurance program (CHIP) (defined in WAC 182-500-0020), and state-only funded health care programs. These programs are provided free or at low cost on a sliding scale to eligible persons based on their income. WAH program regulations for the application process and eligibility determination are found in chapters 182-503 through 182-527 WAC.
2. Health insurance premium tax credits (defined in WAC 182-500-0045). This federal refundable tax credit partially offsets the cost of monthly premiums for qualified health plan (QHP) (defined in WAC 182-500-0090) insurance that an eligible person purchases through the Washington Healthplanfinder. Any advance payments of the tax credit are reconciled annually by the Internal Revenue Service (IRS) when the person files his or her federal tax return.
3. Cost-sharing reductions. Cost-sharing reductions (defined in WAC 182-500-0020) are available to eligible persons enrolled in a silver-level QHP and to American Indians/Alaska Natives enrolled in any QHP.
A person may also apply for and enroll in unsubsidized insurance with a QHP. This unsubsidized insurance is not an insurance affordability program.
Persons choose whether or not to apply for insurance affordability programs. All persons who apply for an insurance affordability program are treated as an applicant for WAH coverage and receive an approval or denial of WAH. Applicants who are denied WAH are reviewed for other insurance affordability programs.

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 182-502-0160 Billing a client.

WAC 182-502-0160 Billing a client.

Effective May 4, 2018

The purpose of this section is to specify the limited circumstances in which:
1. Fee-for-service or managed care clients can choose to self-pay for medical assistance services; and
2. Providers (as defined in WAC 182-500-0085) have the authority to bill fee-for-service or managed care clients for medical assistance services furnished to those clients.
The provider is responsible for:
1. Verifying whether the client is eligible to receive medical assistance services on the date the services are provided;
2. Verifying whether the client is enrolled with a medicaid agency-contracted managed care organization (MCO);
3. Knowing the limitations of the services within the scope of the eligible client's medical program (see WAC 182-501-0050 (4)(a) and 182-501-0065);
4. Informing the client of those limitations;
5. Exhausting all applicable medicaid agency or agency-contracted MCO processes necessary to obtain authorization for requested service(s);
6. Ensuring that translation or interpretation is provided to clients with limited English proficiency (LEP) who agree to be billed for services in accordance with this section; and
7. Retaining all documentation which demonstrates compliance with this section.
Unless otherwise specified in this section, providers must accept as payment in full the amount paid by the agency or agency-contracted MCO for medical assistance services furnished to clients. See 42 C.F.R. § 447.15.
A provider must not bill a client, or anyone on the client's behalf, for any services until the provider has completed all requirements of this section, including the conditions of payment described in the agency's rules, the agency's fee-for-service billing instructions, and the requirements for billing the agency-contracted MCO in which the client is enrolled, and until the provider has then fully informed the client of his or her covered options. A provider must not bill a client for:
1. Any services for which the provider failed to satisfy the conditions of payment described in the agency's rules, the agency's fee-for-service billing instructions, and the requirements for billing the agency-contracted MCO in which the client is enrolled.
2. A covered service even if the provider has not received payment from the agency or the client's MCO.
3. A covered service when the agency or its designee denies an authorization request for the service because the required information was not received from the provider or the prescriber under WAC 182-501-0165 (7)(c)(i).
If the requirements of this section are satisfied, then a provider may bill a fee-for-service or a managed care client for a covered service, defined in WAC 182-501-0050(9), or a noncovered service, defined in WAC 182-501-0050(10) and 182-501-0070. The client and provider must sign and date the HCA form 13-879, Agreement to Pay for Healthcare Services, before the service is furnished. Form 13-879, including translated versions, is available to download at https://www.dshs.wa.gov/fsa/forms. The requirements for this subsection are as follows:
1. The agreement must:
  1. Indicate the anticipated date the service will be provided, which must be no later than ninety calendar days from the date of the signed agreement;
  2. List each of the services that will be furnished;
  3. List treatment alternatives that may have been covered by the agency or agency-contracted MCO;
  4. Specify the total amount the client must pay for the service;
  5. Specify what items or services are included in this amount (such as preoperative care and postoperative care). See WAC 182-501-0070(3) for payment of ancillary services for a noncovered service;
  6. Indicate that the client has been fully informed of all available medically appropriate treatment, including services that may be paid for by the agency or agency-contracted MCO, and that he or she chooses to get the specified service(s);
  7. Specify that the client may request an exception to rule (ETR) in accordance with WAC 182-501-0160 when the agency or its designee denies a request for a noncovered service and that the client may choose not to do so;
  8. Specify that the client may request an administrative hearing in accordance with chapter 182-526 WAC to appeal the agency's or its designee denial of a request for prior authorization of a covered service and that the client may choose not to do so;
  9. Be completed only after the provider and the client have exhausted all applicable agency or agency-contracted MCO processes necessary to obtain authorization of the requested service, except that the client may choose not to request an ETR or an administrative hearing regarding agency or agency designee denials of authorization for requested service(s); and
  10. Specify which reason in subsection (b) below applies.
2. The provider must select on the agreement form one of the following reasons (as applicable) why the client is agreeing to be billed for the service(s). The service(s) is:
  1. Not covered by the agency or the client's agency-contracted MCO and the ETR process as described in WAC 182-501-0160 has been exhausted and the service(s) is denied;
  2. Not covered by the agency or the client's agency-contracted MCO and the client has been informed of his or her right to an ETR and has chosen not to pursue an ETR as described in WAC 182-501-0160;
  3. Covered by the agency or the client's agency-contracted MCO, requires authorization, and the provider completes all the necessary requirements; however the agency or its designee denied the service as not medically necessary (this includes services denied as a limitation extension under WAC 182-501-0169); or
  4. Covered by the agency or the client's agency-contracted MCO and does not require authorization, but the client has requested a specific type of treatment, supply, or equipment based on personal preference which the agency or MCO does not pay for and the specific type is not medically necessary for the client.
3. For clients with limited English proficiency, the agreement must be the version translated in the client's primary language and interpreted if necessary. If the agreement is translated, the interpreter must also sign it;
4. The provider must give the client a copy of the agreement and maintain the original and all documentation which supports compliance with this section in the client's file for six years from the date of service. The agreement must be made available to the agency or its designee for review upon request; and
5. If the service is not provided within ninety calendar days of the signed agreement, a new agreement must be completed by the provider and signed by both the provider and the client.
There are limited circumstances in which a provider may bill a client without executing form 13-879, Agreement to Pay for Healthcare Services, as specified in subsection (5) of this section. The following are those circumstances:
1. The client, the client's legal guardian, or the client's legal representative:
  1. Was reimbursed for the service directly by a third party (see WAC 182-501-0200); or
  2. Refused to complete and sign insurance forms, billing documents, or other forms necessary for the provider to bill the third party insurance carrier for the service.
2. The client represented himself/herself as a private pay client and not receiving medical assistance when the client was already eligible for and receiving benefits under a medical assistance program. In this circumstance, the provider must:
  1. Keep documentation of the client's declaration of medical coverage. The client's declaration must be signed and dated by the client, the client's legal guardian, or the client's legal representative; and
  2. Give a copy of the document to the client and maintain the original for six years from the date of service, for agency or the agency's designee review upon request.
3. The bill counts toward the financial obligation of the client or applicant (such as spenddown liability, client participation as described in chapters 182-513 and 182-515 WAC, emergency medical expense requirement, deductible, or copayment required by the agency or its designee). See subsection (7) of this section for billing a medically needy client for spenddown liability;
4. The client is placed in the agency's or an agency-contracted MCO's patient review and coordination (PRC) program and obtains nonemergency services from a nonpharmacy provider that is not assigned or appropriately referred provider as described in WAC 182-501-0135;
5. The client is a dual-eligible client with medicare Part D coverage or similar creditable prescription drug coverage and the conditions of WAC 182-530-7700 (2)(a)(iii) are met;
6. The service is within a service category excluded from the client's benefits package. See WAC 182-501-0060;
7. The services were noncovered ambulance services (see WAC 182-546-0250(2));
8. A fee-for-service client chooses to receive nonemergency services from a provider who is not contracted with the agency or its designee after being informed by the provider that he or she is not contracted with the agency or its designee and that the services offered will not be paid by the client's health care program; and
  1. An agency-contracted MCO enrollee chooses to receive nonemergency services from providers outside of the MCO's network without authorization from the MCO, i.e., a nonparticipating provider.
Under chapter 182-519 WAC, an individual who has applied for medical assistance is required to spend down excess income on health care expenses to become eligible for coverage under the medically needy program. An individual must incur health care expenses greater than or equal to the amount that he or she must spend down. The provider is prohibited from billing the individual for any amount in excess of the spenddown liability assigned to the bill.
There are situations in which a provider must refund the full amount of a payment previously received from or on behalf of an individual and then bill the agency for the covered service that had been furnished. In these situations, the individual becomes eligible for a covered service that had already been furnished. Providers must then accept as payment in full the amount paid by the agency or its designee or managed care organization for medical assistance services furnished to clients. These situations are as follows:
1. The individual was not receiving medical assistance on the day the service was furnished. The individual applies for medical assistance later in the same month in which the service was provided and the agency or its designee makes the individual eligible for medical assistance from the first day of that month;
2. The client receives a delayed certification for medical assistance as defined in WAC 182-500-0025; or
3. The client receives a certification for medical assistance for a retroactive period according to 42 C.F.R. § 435.914(a) and defined in WAC 182-500-0095.
Regardless of any written, signed agreement to pay, a provider may not bill, demand, collect, or accept payment or a deposit from a client, anyone on the client's behalf, or the agency or its designee for:
1. Copying, printing, or otherwise transferring health care information, as the term health care information is defined in chapter 70.02 RCW, to another health care provider. This includes, but is not limited to:
  1. Medical/dental charts;
  2. Radiological or imaging films; and
  3. Laboratory or other diagnostic test results.
2. Missed, canceled, or late appointments;
3. Shipping and/or postage charges;
4. "Boutique," "concierge," or enhanced service packages (e.g., newsletters, 24/7 access to provider, health seminars) as a condition for access to care; or
5. The price differential between an authorized service or item and an "upgraded" service or item (e.g., a wheelchair with more features; brand name versus generic drugs).

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 182-501-0135 Patient review and coordination (PRC).

WAC 182-501-0135 Patient review and coordination (PRC).

Effective August 1, 2023

Patient review and coordination (PRC) is a health and safety program that coordinates care and ensures clients enrolled in PRC use services appropriately and in accordance with agency rules and policies.
1. PRC applies to medical assistance fee-for-service and managed care clients organization (MCO) enrollees.
2. PRC is authorized under federal medicaid law by 42 U.S.C. 1396n (a)(2) and 42 CFR 431.54.
Definitions. Definitions found in chapter 182-500 WAC and WAC 182-526-0010 apply to this section. The following definitions apply to this section:
"Appropriate use" - Use of healthcare services that are safe and effective for a client's healthcare needs.
"Assigned provider" - An agency-enrolled healthcare provider or one participating with an agency-contracted managed care organization (MCO) who agrees to be assigned as a primary provider and coordinator of services for an FFS client or MCO enrollee in the PRC program. Assigned providers can include a primary care provider (PCP), a pharmacy, a prescriber of controlled substances, and a hospital for nonemergency services.
"At-risk" - A term used to describe one or more of the following:
1. A client with a medical history of:
  1. Seeking and obtaining healthcare services at a frequency or amount that is not medically necessary;
  2. Potential life-threatening events or life-threatening conditions that required or may require medical intervention.
2. Behaviors or practices that could jeopardize a client's medical treatment or health including, but not limited to:
  1. Indications of forging or altering prescriptions;
  2. Referrals from medical personnel, social services personnel, or MCO personnel about inappropriate behaviors or practices that place the client at risk;
  3. Noncompliance with medical or drug and alcohol treatment;
  4. Paying cash for medical services that result in a controlled substance prescription or paying cash for controlled substances;
  5. Arrests for diverting controlled substance prescriptions;
  6. Positive urine drug screen for illicit street drugs or nonprescribed controlled substances;
  7. Negative urine drug screen for prescribed controlled substances; or
  8. Unauthorized use of a client's services card for an unauthorized purpose.
    "Care management"- Services provided to MCO enrollees with multiple health, behavioral, and social needs to improve care coordination, client education, and client self-management skills.
    "Client" - See WAC 182-500-0020.
    "Conflicting" - Drugs or health care services that are incompatible or unsuitable for use together because of undesirable chemical or physiological effects.
    "Contraindicated" - A medical treatment, procedure, or medication that is inadvisable or not recommended or warranted.
    "Duplicative" - Applies to the use of the same or similar drugs and health care services without due medical justification. Example: A client receives health care services from two or more providers for the same or similar condition(s) in an overlapping time frame, or the client receives two or more similarly acting drugs in an overlapping time frame, which could result in a harmful drug interaction or an adverse reaction.
    "Emergency department information exchange (EDIE)" - An internet-delivered service that enables health care providers to better identify and treat high users of the emergency department and special needs patients. When patients enter the emergency room, EDIE can proactively alert health care providers through different venues such as fax, phone, email, or integration with a facility's current electronic medical records.
    "Emergency medical condition" - See WAC 182-500-0030.
    "Emergency services" - See 42 C.F.R. 438.114.
    "Fee-for-service" or "FFS" - See WAC 182-500-0035.
    "Just cause" - A legitimate reason to justify the action taken including but not limited to, protecting the health and safety of the client.
  9. "Managed care organization (MCO) enrollee" - A medical assistance client enrolled in, and receiving health care services from, an agency-contracted managed care organization (MCO).
    "Prescriber of controlled substances" - Any of the following health care professionals who, within their scope of professional practice, are licensed to prescribe and administer controlled substances (see chapter 69.50 RCW, Uniform Controlled Substance Act) for a legitimate medical purpose:
    (a) A physician under chapter 18.71 RCW;
    (b) A physician assistant under chapter 18.71A RCW;
    (c) An osteopathic physician under chapter 18.57 RCW;
    (d) An osteopathic physician assistant under chapter 18.57A RCW; and
    (e) An advanced registered nurse practitioner under chapter 18.79 RCW.
    "Primary care provider" or "PCP" - A person licensed or certified under Title 18 RCW including, but not limited to, a physician, an advanced registered nurse practitioner (ARNP), or a physician assistant (PA) who supervises, coordinates, and provides health care services to a client, initiates referrals for specialty and ancillary care, and maintains the client's continuity of care.
Clients selected for PRC review. The agency or agency's designee selects a client for PRC review when either or both of the following occur:
1. An agency or MCO claims utilization review report indicates the client has not used health care services appropriately; or
2. Medical providers, social service agencies, or other concerned parties have provided direct referrals to the agency or MCO.
Clients not selected for PRC review. Clients are not reviewed or placed into the PRC program when they :
1. Are in foster care;
2. Are covered under state-only funded programs;
3. Do not have medicaid as the primary payor; or
4. Are covered under the alien emergency medical (AEM) program according to WAC 182-507-0115.
Prior authorization. When an FFS client is selected for PRC review the prior authorization process as defined in WAC 182-500-0085 may be required:
1. Before or during a PRC review; or
2. When the FFS client is currently in the PRC program.
Review for placement in the PRC program. When the agency or MCO selects a client for PRC review, the agency or MCO staff, with clinical oversight, reviews either the client's medical history or billing history, or both, to determine if the client has used health care services at a frequency or amount that is not medically necessary (42 CFR 431.54(e)).
Usage guidelines for PRC placement. Agency or MCO staff use the following usage guidelines to determine PRC placement. A client may be reviewed for placement in the PRC program when the review shows the usage is not medically necessary and either the client's medical history or billing history, or both, documents any of the following:
1. Any two or more of the following conditions occurred in a period of 90 consecutive calendar days in the previous 12 months. The client:
  1. Received services from four or more different providers, including physicians, ARNPs, and PAs not located in the same clinic or practice;
  2. Had prescriptions filled by four or more different pharmacies;
  3. Received 10 or more prescriptions;
  4. Had prescriptions written by four or more different prescribers not located in the same clinic or practice;
  5. Received similar services in the same day not located in the same clinic or practice; or
  6. Had 10 or more office visits;
2. Any one of the following occurred within a period of 90 consecutive calendar days in the previous 12 months. The client:
  1. Made two or more emergency department visits;
  2. Exhibits "at-risk" usage patterns;
  3. Made repeated and documented efforts to seek health care services that are not medically necessary; or
  4. Was counseled at least once by a health care provider, or an agency or MCO staff member with clinical oversight, about the appropriate use of health care services;
3. The client received prescriptions for controlled substances from two or more different prescribers not located in the same clinic or practice in any one month within the 90-day review period; or .
4. The client has either a medical history or billing history, or both, that demonstrates a pattern of the following at any time in the previous 12 months:
  1. Using health care services in a manner that is duplicative, excessive, or contraindicated;
  2. Seeking conflicting health care services, drugs, or supplies that are not within acceptable medical practice;
PRC review results. As a result of the PRC review, the agency or MCO staff may take any of the following steps:
1. Determine that no action is needed and close the client's file;
2. Send the client and, if applicable, the client's authorized representative a one-time only written notice of concern with information on specific findings and notice of potential placement in the PRC program; or
3. Determine that the usage guidelines for PRC placement establish that the client has used health care services at an amount or frequency that is not medically necessary, in which case one or more of the following actions take place:
  1. The MCO:
    1. Refers the MCO enrollee:
      1. For education on appropriate use of health care services; or
      2. To other support services or agencies; or
    2. Places the MCO enrollee into the PRC program for an initial placement period of no less than 24 months. For MCO enrollees younger than 18 years of age, the MCO must get agency approval before placing the MCO enrollee into the PRC program; or
  2. The agency places the FFS client into the PRC program for an initial placement period of no less than 24 months.
Initial placement in the PRC program.
1. When an FFS client is initially placed in the PRC program, the agency places the FFS client for no less than 24 months with a primary care provider (PCP) for care coordination and a pharmacy for all medication prescriptions and one or more of the following types of health care providers:
  1. Prescriber of all controlled substances if different than PCP;
  2. Hospital for nonemergency services unless referred by the assigned PCP or a specialist. An FFS client may receive covered emergency services from any hospital; or
  3. Another qualified provider type, as determined by agency program staff on a case-by-case basis; or
  4. Additional pharmacies on a case-by-case basis.
2. Based on a medical necessity determination, the agency may make an exception to PRC rules when in the best interest of the client. See WAC 182-501-0165 and 182-501-0160.
3. When an MCO enrollee is initially placed in the PRC program, the MCO restricts the MCO enrollee for no less than 24 months with a primary care provider (PCP) for care coordination and a primary pharmacy for all medication prescriptions and one or more of the following types of health care providers:
  1. Prescriber of controlled substances if different than PCP;
  2. Hospital for nonemergency services unless referred by the assigned PCP or a specialist. An MCO enrollee may receive covered emergency services from any hospital;
  3. Another qualified provider type, as determined by MCO program staff on a case-by-case basis; or
  4. Additional pharmacies on a case-by-case basis.
MCO enrollees changing MCOs. MCO enrollees:
1. Remain in the same MCO for no less than 12 months for initial placement and whenever the enrollee changes MCOs, unless:
  1. The MCO enrollee moves to a residence outside the MCO's service area and the MCO is not available in the new location;
  2. The MCO enrollee's assigned PCP no longer participates with the MCO and is available in another MCO, and the MCO enrollee wishes to remain with the current provider;
  3. The MCO enrollee is in a voluntary enrollment program or a voluntary enrollment county.
  4. The MCO enrollee is in the address confidentiality program (ACP), indicated by P.O. Box 257, Olympia, WA 98507; or
  5. The MCO enrollee is an American Indian/Alaska native.
2. Placed in the PRC program must remain in the PRC program for no less than 24 months regardless of whether the MCO enrollee changes MCOs or becomes an FFS client.
Notifying the client about placement in the PRC program. When the client is initially placed in the PRC program, the agency or the MCO sends the client and, if applicable, the client's authorized representative, a written notice that:
1. Informs the client of the reason for the PRC program placement;
2. Informs the client of the providers the client has been assigned to;
3. Directs the client to respond to the agency or MCO to take the following actions if applicable:
  1. Change assigned providers, subject to agency or MCO approval;
  2. Submit additional health care information, justifying the client's use of health care services; or
  3. Request assistance, if needed, from agency or MCO program staff; and
4. Informs the client of administrative hearing or appeal rights (see subsection (16) of this section).
Selection and role of assigned provider. A client has a limited choice of providers.
1. The following providers are not available:
  1. A provider who is being reviewed by the agency or licensing authority regarding quality of care;
  2. A provider who has been suspended or disqualified from participating as an agency-enrolled or MCO-contracted provider; or
  3. A provider whose business license is suspended or revoked by the licensing authority.
2. For a client placed in the PRC program, the assigned:
  1. Provider(s) must be located in the client's local geographic area, in the client's selected MCO, and be reasonably accessible to the client.
    1. PCP supervises and coordinates health care services for the client, including continuity of care and referrals to specialists when necessary.
      (A) The PCP:
      (I) Provides the plan of care for clients that have documented use of the emergency department for a reason that is not deemed to be an emergency medical condition;
      (II) Files the plan of care with each emergency department that the client is using or with the emergency department information exchange;
      (III) Makes referrals to behavioral health treatment for clients who are using the emergency department for behavioral health treatment issues.
    2. (B) The assigned PCP must be one of the following:
      (I) A physician;
      (II) An advanced registered nurse practitioner (ARNP); or
      (III) A licensed physician assistant (PA), practicing with a supervising physician.
      (iii) Prescriber of controlled substances prescribes all controlled substances for the client;
      (iv) Pharmacy fills all prescriptions for the client; and
      (v) Hospital provides all hospital nonemergency services.
3. A client placed in the PRC program must remain with the assigned provider for 12 months after the assignments are made, unless:
  1. The client moves to a residence outside the provider's geographic area;
  2. The provider moves out of the client's local geographic area and is no longer reasonably accessible to the client;
  3. The provider refuses to continue to serve the client;
  4. The client did not select the provider. The client may request to change an assigned provider once within 30 calendar days of the assignment;
  5. The MCO enrollee's assigned PCP no longer participates with the MCO. In this case, the MCO enrollee may select a new provider from the list of available providers in the MCO network or follow the assigned provider to the new MCO; or
  6. The client is in the address confidentiality program (ACP), indicated by P.O. Box 257, Olympia, WA 98507.
4. When an assigned prescribing provider no longer contracts with the agency or the MCO:
  1. All prescriptions from the provider are invalid 30 calendar days following the date the contract ends;
  2. The client must choose or be assigned another provider according to the requirements in this section.
PRC placement.
1. The initial PRC placement is no less than 24 consecutive months.
2. The second period of PRC placement is no less than an additional 36 consecutive months.
3. Each subsequent PRC placement is no less than 72 consecutive months.
Agency or MCO review of a PRC placement period. The agency or MCO reviews a client's use of health care services before the end of each PRC placement period described in subsection (13) of this section using the guidelines in subsection (7) of this section.
1. The agency or MCO assigns the next PRC placement if the usage guidelines for PRC placement in subsection (7) of this section apply to the client.
2. When the agency or MCO assigns a subsequent PRC placement, the agency or MCO sends the client and, if applicable, the client's authorized representative, a written notice informing the client:
  1. Of the reason for the subsequent PRC program placement;
  2. Of the length of the subsequent PRC placement;
  3. That the current providers assigned to the client continue to be assigned to the client during the subsequent PRC placement;
  4. That all PRC program rules continue to apply;
  5. Of administrative hearing or appeal rights (see subsection (16) of this section); and
  6. Of the rules that support the decision.
3. The agency or MCO may remove a client from PRC placement if the client:
  1. Successfully completes a treatment program that is provided by a substance use disorder (SUD) service provider certified by the agency under chapter 182-538D WAC;
  2. Submits documentation of completion of the approved treatment program to the agency; and
  3. Maintains appropriate use of health care services within the usage guidelines described in subsection (7) of this section for six consecutive months after the date the treatment ends; or
  4. Successfully stabilizes due to the usage of treatment medications including, but not limited to, Buprenorphine.
4. The agency or MCO determines the appropriate placement for a client who has been placed back into the program.
5. A client remains placed in the PRC program regardless of change in eligibility program type or change in address.
Client financial responsibility. A client placed in the PRC program may be billed by a provider and held financially responsible for nonemergency health care services obtained from a nonpharmacy provider when the provider is not an assigned or appropriately referred provider as described in subsection (12) of this section. See WAC 182-502-0160.
Right to administrative hearing or appeal.
1. An FFS client who disagrees with an agency decision regarding placement or continued placement in the PRC program has the right to an administrative hearing regarding placement. An FFS client must request an administrative hearing from the agency within 90 days of the written notice of placement or continued placement to exercise this right.
2. An MCO enrollee who disagrees with an MCO decision regarding placement or continued placement in the PRC program has a right to appeal this decision in the same manner as an adverse benefit determination under chapter 182-538 WAC.
3. The agency conducts an administrative hearing according to chapter 182-526 WAC.
4. A client who requests an administrative hearing or appeal within 10 calendar days from the date of the written notice of an initial PRC placement will not be placed in the PRC program until ordered by an administrative law judge (ALJ) or review judge.
5. A client who requests an administrative hearing or appeal more than 10 calendar days from the date of the written notice of initial PRC placement will remain placed in the PRC program until a final administrative order is entered that orders the client's removal from the program.
6. A client who requests an administrative hearing or appeal in all other cases and who has already been assigned providers will remain placed in the PRC program unless a final administrative order is entered that orders the client's removal from the program.
7. An ALJ may rule the client be placed in the PRC program prior to the date the record is closed and before the date the initial order is issued based on a showing of just cause.

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 182-526-0595 Process after review response deadline.

WAC 182-526-0595 Process after review response deadline.

Effective March 16, 2017

After the response deadline, the record on review is closed unless the review judge finds there is a good reason to keep it open.
A review judge is assigned to review the initial order after the record on review is closed. To find out which judge is assigned, call the board of appeals.
After the record is closed, the assigned review judge:
1. Reviews the record, including the initial order; and
2. Enters a final order that affirms, modifies, dismisses or reverses the initial order; or
3. Returns the case to the office of administrative hearings for further action.

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 182-526-0590 Response to a request for review

WAC 182-526-0590 Response to a request for review.

Effective February 1, 2013

A party does not have to respond to the request for review. A response is optional.
If a party decides to respond, that party must file the response so that the board of appeals (BOA) receives it on or before the seventh business day after the date the other party's review request was served to the party by the BOA.
The party should send a copy of the response to all other parties or their representatives.
A review judge may extend the deadline in subsection (2) of this section if a party asks for more time before the deadline to respond expires and gives a good reason.
If a party asks for more time to respond, the time period provided by this section for responding to the review request, including any extensions, does not count against any deadline for a review judge to enter the final order.
A review judge may accept and consider a party's response even if it is filed after the deadline.

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 182-526-0580 Deadline for requesting review of an initial order by a review judge.

WAC 182-526-0580 Deadline for requesting review of an initial order by a review judge.

Effective March 16, 2017

The board of appeals (BOA) must receive the written review request of an initial order on or before 5:00 p.m. on the twenty-first calendar day after the initial order was served, unless an extension of the deadline is granted by the review judge. A party may file the review request by facsimile transmission (fax). A copy of the review request should also be mailed to BOA.
A review judge may extend the deadline to request review if a party:
1. Asks for more time before the deadline expires; and
2. Gives a good reason for more time.
A review judge may accept a review request after the twenty-one calendar day deadline only if:
1. BOA receives the review request on or before the thirtieth calendar day after the deadline; and
2. A party shows good cause for missing the deadline.
The time periods provided by this section for requesting review of an initial order, including any extensions, does not count against a deadline, if any, for a review judge to enter the final order.

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 182-526-0575 How to request review of an initial order.

WAC 182-526-0575 How to request review of an initial order.

Effective March 16, 2017

A party must make the request for review of an initial order in writing and file the request with the board of appeals (BOA) at the address given in WAC 182-526-0030 and within the deadlines set forth in WAC 182-526-0580.
The request for review should identify the parts of the initial order with which the party disagrees and should identify the evidence in the hearing record supporting the party's position.
The party seeking review should also send a copy of the review request to the other parties.
After receiving a request for review of an initial order, BOA serves a copy on the other parties, their representatives, and the office of administrative hearings. The other parties and their representatives may respond as described in WAC 182-526-0590.

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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