WAC 388-501-0050 through 388-501-0065 describe the health
care services available to a client on a fee-for-service basis or to a client
enrolled in a managed care organization (MCO) (defined in WAC 388-538-050). For
the purposes of this section, health care services includes treatment,
equipment, related supplies, and drugs. WAC 388-501-0070 describes noncovered
services.
(1) Health care service
categories listed in WAC
388-501-0060 do not represent a contract for health
care services.
(2) For the provider
to receive payment, the client must be eligible for the covered health care
service on the date the health care service is performed or provided.
(3) Under the department's fee-for-service
programs, providers must be enrolled with the department and meet the
requirements of chapter
388-502 WAC to be paid for furnishing health care
services to clients.
(4) The
department pays only for the health care services that are:
(a) Within the scope of the client's medical
program;
(b) Covered - See
subsection (9) of this section;
(c)
Ordered or prescribed by a health care provider who meets the requirements of
chapter
388-502 WAC;
(e) Submitted for authorization, when
required, in accordance with WAC
388-501-0163;
(f) Approved, when required, in accordance
with WAC
388-501-0165;
(g)
Furnished by a provider according to chapter
388-502 WAC; and
(h) Billed in accordance with department
program rules and the department's current published billing instructions and
numbered memoranda.
(5)
The department does not pay for any health care service requiring prior
authorization from the department, if prior authorization was not obtained
before the health care service was provided; unless:
(a) The client is determined to be
retroactively eligible for medical assistance; and
(b) The request meets the requirements of
subsection (4) of this section.
(6) The department does not reimburse clients
for health care services purchased out-of-pocket.
(7) The department does not pay for the
replacement of department-purchased equipment, devices, or supplies which have
been sold, gifted, lost, broken, destroyed, or stolen as a result of the
client's carelessness, negligence, recklessness, or misuse unless:
(a) Extenuating circumstances exist that
result in a loss or destruction of department-purchased equipment, devices, or
supplies, through no fault of the client that occurred while the client was
exercising reasonable care under the circumstances; or
(b) Otherwise allowed under chapter
388-500
WAC.
(8) The
department's refusal to pay for replacement of equipment, device, or supplies
will not extend beyond the limitations stated in specific department program
rules.
(9)
Covered health
care services
(a) Covered health care
services are either:
(i) "Federally mandated"
- Means the state of Washington is required by federal regulation (
42 C.F.R.
440.210 and 220) to cover the health care
service for medicaid clients; or
(ii) "State-option" - Means the state of
Washington is not federally mandated to cover the health care service but has
chosen to do so at its own discretion.
(b) The department may limit the scope,
amount, duration, and/or frequency of covered health care services. Limitation
extensions are authorized according to WAC
388-501-0169.
(10)
Noncovered health care
services
(a) The department does not
pay for any health care service:
(i) That
federal or state laws or regulations prohibit the department from covering;
or
(ii) Listed as noncovered in WAC
388-501-0070 or in any other program rule. The department evaluates a request
for a noncovered health care service only if an exception to rule is requested
according to the provisions in WAC
388-501-0160.
(b) When a noncovered health care service is
recommended during the Early and Periodic Screening, Diagnosis, and Treatment
(EPSDT) exam and then ordered by a provider, the department evaluates the
health care service according to the process in WAC
388-501-0165 to determine
if it is medically necessary, safe, effective, and not experimental (see WAC
388-534-0100 for EPSDT rules).
