Wash. Admin. Code § 182-500-0085 - Medical assistance definitions-P

Current through Register Vol. 21-18, September 15, 2021

"Patient transportation" means client transportation to or from covered health care services under federal and state health care programs.

"Physician" means a doctor of medicine, osteopathy, naturopathy, or podiatry who is legally authorized to perform the functions of the profession by the state in which the services are performed.

"Prescribing provider" means a health care professional authorized by law or rule to prescribe drugs to Washington apple health (WAH) clients.

"Prior authorization" is the requirement that a provider must request, on behalf of a client and when required by rule or agency billing instructions, the agency or the agency's designee's approval to provide a health care service before the client receives the health care service , prescribed drug, device, or drug-related supply. The agency or the agency's designee's approval is based on medical necessity. Receipt of prior authorization does not guarantee payment. Expedited prior authorization and limitation extension are types of prior authorization.

"Prosthetic device" means a preventive, replacement, corrective, or supportive device prescribed by a physician or other licensed practitioner, within the scope of his or her practice under state law.

"Provider" means an institution, agency, or person that is licensed, certified, accredited, or registered according to Washington state law, and has:

(a) A signed core provider agreement or contract with the agency or the agency's desig-nee, and is authorized to provide health care, goods, and services to WAH clients; or
(b) Authorization from a managed care organization (MCO) that contracts with the agency or the agency's designee to provide health care, goods, and services to eligible WAH clients enrolled in the MCO plan.

"Provider guide" means an agency publication that describes a specific benefit covered under WAH, which includes client eligibility verification instructions, provider responsibilities, authorization requirements, coverage, billing, and how to complete and submit claims.

"Public institution" see "institution" in WAC 182-500-0050.


Wash. Admin. Code § 182-500-0085
Amended by WSR 14-05-001, filed 2/5/2014, effective 3/8/2014 Amended by WSR 15-21-063, Filed 10/19/2015, effective 11/19/2015
Statutory Authority: 42 C.F.R. 455.410, RCW 41.05.021. WSR 13-19-037, § 182-500-0085, filed 9/11/13, effective 10/12/13. WSR 11-14-075, recodified as § 182-500-0085, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 2011 1st sp.s. c 15 . WSR 11-14-053, § 388-500-0085, filed 6/29/11, effective 7/30/11. WSR 13-18-003, § 182-500-0085, filed 8/21/2013, effective 9/21/2013

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