Wash. Admin. Code § 182-550-2590 - Agency prior authorization requirements for Level 1 and Level 2 LTAC services
(1) The medicaid
agency requires prior authorization for Level 1 and Level 2 long term acute
care (LTAC) inpatient stays. The prior authorization process includes all the
following:
(a) For an initial 30-day stay:
(i) The client must:
(A) Be eligible under one of the programs
listed in WAC 182-550-2575; and
(B)
Require Level 1 or Level 2 LTAC services as defined in WAC
182-550-1050.
(ii) The
LTAC provider of services must:
(A) Before
admitting the client to the LTAC hospital, submit a request for prior
authorization to the agency as published in the agency's LTAC billing
instructions;
(B) Include
sufficient medical information to justify the requested initial stay;
(C) Obtain prior authorization from the
agency's medical director or designee, when accepting the client from the
transferring hospital; and
(D) Meet
all the requirements in WAC 182-550-2580.
(b) For any extension of stay, the criteria
in (a) of this subsection must be met, and the LTAC provider of services must
submit a request for the extension of stay to the agency with sufficient
medical justification.
(2) The agency authorizes Level 1 or Level 2
LTAC services for initial stays or extensions of stay based on the client's
circumstances and the medical justification received.
(3) A client who does not agree with a
decision regarding a length of stay has a right to an administrative hearing
under chapter 182-526 WAC. After receiving a request for an administrative
hearing, the agency may request additional information from the client and the
facility, or both. After the agency reviews the available information, the
result may be:
(a) A reversal of the initial
agency decision;
(b) Resolution of
the client's issue(s); or
(c) An
administrative hearing conducted according to chapter 182-526 WAC.
(4) The agency may authorize an
administrative day rate payment, as well as payment for medically necessary
ancillary services as determined by the agency, pharmacy services, and
pharmaceuticals, for a client who meets one or more of the following. The
client:
(a) Does not meet the requirements for
Level 1 or Level 2 LTAC services;
(b) Is waiting for placement in another
hospital or other facility; or
(c)
If appropriate, is waiting to be discharged to the client's
residence.
Notes
11-14-075, recodified as §182-550-2590, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. 08-21-039, § 388-550-2590, filed 10/8/08, effective 11/8/08; 07-11-129, § 388-550-2590, filed 5/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090. 02-14-162, § 388-550-2590, filed 7/3/02, effective 8/3/02.
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(1) The medicaid agency requires prior authorization for Level 1 and Level 2 long term acute care (LTAC) inpatient stays. The prior authorization process includes all the following:
(a) For an initial 30-day stay:
(i) The client must:
(A) Be eligible under one of the programs listed in WAC 182-550-2575; and
(B) Require Level 1 or Level 2 LTAC services as defined in WAC 182-550-1050.
(ii) The LTAC provider of services must:
(A) Before admitting the client to the LTAC hospital, submit a request for prior authorization to the agency by fax, electronic mail, or telephone, as published in the agency's LTAC billing instructions;
(B) Include sufficient medical information to justify the requested initial stay;
(C) Obtain prior authorization from the agency's medical director or designee, when accepting the client from the transferring hospital; and
(D) Meet all the requirements in WAC 182-550-2580.
(b) For any extension of stay, the criteria in (a) of this subsection must be met, and the LTAC provider of services must submit a request for the extension of stay to the agency with sufficient medical justification.
(2) The agency authorizes Level 1 or Level 2 LTAC services for initial stays or extensions of stay based on the client's circumstances and the medical justification received.
(3) A client who does not agree with a decision regarding a length of stay has a right to a fair hearing under chapter 182-526 WAC. After receiving a request for a fair hearing, the agency may request additional information from the client and the facility, or both. After the agency reviews the available information, the result may be:
(a) A reversal of the initial agency decision;
(b) Resolution of the client's issue(s); or
(c) A fair hearing conducted according to chapter 182-526 WAC.
(4) The agency may authorize an administrative day rate payment, as well as payment for medically necessary ancillary services as determined by the agency, pharmacy services, and pharmaceuticals, for a client who meets one or more of the following. The client:
(a) Does not meet the requirements for Level 1 or Level 2 LTAC services;
(b) Is waiting for placement in another hospital or other facility; or
(c) If appropriate, is waiting to be discharged to the client's residence.
Notes
11-14-075, recodified as §182-550-2590, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. 08-21-039, § 388-550-2590, filed 10/8/08, effective 11/8/08; 07-11-129, § 388-550-2590, filed 5/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090. 02-14-162, § 388-550-2590, filed 7/3/02, effective 8/3/02.