Current through Register Vol. 24-18, September 15, 2024
(1)
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.
(a) PRC applies to
medical assistance fee-for-service (FFS) clients and managed care organization
(MCO) enrollees.
(b) PRC is
authorized under federal medicaid law by
42 U.S.C.
1396n(a)(2) and 42 C.F.R.
431.54.
(2)
Definitions. Definitions found in chapter 182-500 WAC and WAC
182-526-0010 apply to this
section. The following definitions apply to this section:
"Agency's designee" - See WAC
182-500-0010.
"Appropriate use" - Use of health care services
that are safe and effective for a client's health care needs.
"Assigned provider" - An agency-enrolled health
care 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:
(a) A client with a
medical history of:
(i) Seeking and obtaining
health care services at a frequency or amount that is not medically necessary;
or
(ii) Potential life-threatening
events or life-threatening conditions that required or may require medical
intervention.
(b)
Behaviors or practices that could jeopardize a client's medical treatment or
health including, but not limited to:
(i)
Indications of forging or altering prescriptions;
(ii) Referrals from medical personnel, social
services personnel, or MCO personnel about inappropriate behaviors or practices
that place the client at risk;
(iii) Noncompliance with medical or drug and
alcohol treatment;
(iv) Paying cash
for medical services that result in a controlled substance prescription or
paying cash for controlled substances;
(v) Arrests for diverting controlled
substance prescriptions;
(vi)
Positive urine drug screen for illicit street drugs or non-prescribed
controlled substances;
(vii)
Negative urine drug screen for prescribed controlled substances; or
(viii) 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.
"Fee-for-service client" or "FFS
client" - A client not enrolled in an agency-contracted MCO.
"Just cause" - A legitimate reason to justify
the action tak-en including, but not limited to, protecting the health and
safety of the client.
"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.
(3)
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:
(a) An agency or MCO claims utilization
review report indicates the client has not used health care services
appropriately; or
(b) Medical
providers, social service agencies, or other concerned parties have provided
direct referrals to the agency or MCO.
(4)
Clients not selected for PRC
review. Clients are not reviewed or placed into the PRC program when
they:
(a) Are in foster care;
(b) Are covered under state-only funded
programs;
(c) Do not have medicaid
as the primary payor; or
(d) Are
covered under the alien emergency medical (AEM) program, according to WAC
182-507-0115.
(5)
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:
(a) Before or during a PRC review;
or
(b) When the FFS client is
currently in the PRC program.
(6)
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 C.F.R.
431.54(e).
(7)
Usage guidelines for PRC
placement. Agency or MCO staff use the following usage guidelines to
initiate review for 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:
(a) Any two or more of the
following conditions occurred in a period of 90 consecutive calendar days in
the previous 12 months. The client:
(i)
Received services from four or more different providers, including physicians,
ARNPs, and PAs not located in the same clinic or practice;
(ii) Had prescriptions filled by four or more
different pharmacies;
(iii)
Received 10 or more prescriptions;
(iv) Had prescriptions written by four or
more different prescribers not located in the same clinic or
practice;
(v) Received similar
services in the same day not located in the same clinic or practice;
or
(vi) Had 10 or more office
visits;
(b) Any one of
the following occurred within a period of 90 consecutive calendar days in the
previous 12 months. The client:
(i) Made two
or more emergency department visits;
(ii) Exhibits "at-risk" usage
patterns;
(iii) Made repeated and
documented efforts to seek health care services that are not medically
necessary; or
(iv) 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;
(c) 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
(d)
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:
(i) Using health care services in a manner
that is duplicative, excessive, or contraindicated; or
(ii) Seeking conflicting health care
services, drugs, or supplies that are not within acceptable medical
practice.
(8)
PRC review results. As a result of the PRC review, the agency or
MCO may take any of the following steps:
(a)
Determine that no action is needed and close the client's file;
(b) 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
(c) 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:
(i) The MCO:
(A) Refers the MCO enrollee:
(I) For education on appropriate use of
health care services; or
(II) To
other support services or agencies; or
(B) 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
(ii) The agency places the FFS client into
the PRC program for an initial placement period of no less than 24 months.
(9)
Initial placement in the PRC program.
(a) When an FFS client is initially placed in
the PRC pro-gram, 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:
(i) Prescriber of controlled
substances if different than PCP;
(ii) Hospital for nonemergency services
unless referred by the assigned PCP or a specialist. An FFS client may receive
covered emergency services from any hospital;
(iii) Another qualified provider type, as
determined by agency program staff on a case-by-case basis; or
(iv) Additional pharmacies on a case-by-case
basis.
(b) 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.
(c) 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:
(i)
Prescriber of controlled substances if different than PCP;
(ii) Hospital for nonemergency services
unless referred by the assigned PCP or a specialist. An MCO enrollee may
receive covered emergency services from any hospital;
(iii) Another qualified provider type, as
determined by MCO program staff on a case-by-case basis; or
(iv) Additional pharmacies on a case-by-case
basis.
(10)
MCO enrollees changing MCOs. MCO enrollees:
(a) Remain in the same MCO for no less than
12 months for initial placement and whenever the enrollee changes MCOs, unless:
(i) The MCO enrollee moves to a residence
outside the MCO's service area and the MCO is not available in the new
location;
(ii) 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;
(iii) The MCO enrollee is in a voluntary
enrollment program or a voluntary enrollment county;
(iv) The MCO enrollee is in the address
confidentiality program (ACP), indicated by P.O. Box 257, Olympia, WA 98507;
or
(v) The MCO enrollee is an
American Indian/Alaska Native.
(b) 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.
(11)
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:
(a) Informs the client of the reason for the
PRC program placement;
(b) Informs
the client of the providers the client has been assigned to;
(c) Directs the client to respond to the
agency or MCO to take the following actions if applicable:
(i) Change assigned providers, subject to
agency or MCO approval;
(ii) Submit
additional health care information, justifying the client's use of health care
services; or
(iii) Request
assistance, if needed, from agency or MCO program staff; and
(d) Informs the client of
administrative hearing or appeal rights (see subsection (16) of this
section).
(12)
Selection and role of assigned provider. A client has a limited
choice of providers.
(a) The following
providers are not available:
(i) A provider
who is being reviewed by the agency or licensing authority regarding quality of
care;
(ii) A provider who has been
suspended or disqualified from participating as an agency-enrolled or
MCO-contracted provider; or
(iii) A
provider whose business license is suspended or revoked by the licensing
authority.
(b) For a
client placed in the PRC program, the assigned:
(i) 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.
(ii) 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; and
(III)
Makes referrals to behavioral health treatment for clients who are using the
emergency department for behavioral health treatment issues.
(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.
(c) A client placed in the PRC program must
remain with the assigned providers for 12 months after the assignments are
made, unless:
(i) The client moves to a
residence outside the provider's geographic area;
(ii) The provider moves out of the client's
local geographic area and is no longer reasonably accessible to the
client;
(iii) The provider refuses
to continue to serve the client;
(iv) The client did not select the provider.
The client may request to change an assigned provider once within 30 calendar
days of the assignment;
(v) 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
(vi) The client is in the address
confidentiality program (ACP), indicated by P.O. Box 257, Olympia, WA
98507.
(d) When an
assigned prescribing provider no longer contracts with the agency or the MCO:
(i) All prescriptions from the provider are
invalid 30 calendar days following the date the contract ends; and
(ii) The client must choose or be assigned
another provider according to the requirements in this section.
(13)
PRC
placement.
(a) The initial PRC
placement is no less than 24 consecutive months.
(b) The second PRC placement is no less than
an additional 36 consecutive months.
(c) Each subsequent PRC placement is no less
than 72 consecutive months.
(14)
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.
(a) 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.
(b) 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:
(i) Of the reason for the
subsequent PRC program placement;
(ii) Of the length of the subsequent PRC
placement;
(iii) That the current
providers assigned to the client continue to be assigned to the client during
the subsequent PRC placement;
(iv)
That all PRC program rules continue to apply;
(v) Of administrative hearing or appeal
rights (see subsection (16) of this section); and
(vi) Of the rules that support the
decision.
(c) The agency
or MCO may remove a client from PRC placement if the client:
(i) 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;
(ii) Submits documentation of completion of
the approved treatment program to the agency; and
(iii) 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
(iv) Successfully stabilizes due
to the usage of treatment medications including, but not limited to,
Buprenorphine.
(d) The
agency or MCO determines the appropriate placement for a client who has been
placed back into the program.
(e) A
client remains placed in the PRC program regardless of change in eligibility
program type or change in address.
(15)
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 non-pharmacy 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.
(16)
Right to administrative hearing or
appeal.
(a) 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 this
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.
(b) 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.
(c) The agency conducts an administrative
hearing according to chapter 182-526 WAC.
(d) 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.
(e) 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.
(f) 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.
(g) 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.
Statutory Authority:
RCW
41.05.021 and
2011 1st sp.s. c
50 . 13-05-006, §182-501-0135, filed 2/6/13,
effective 3/9/13. 11-14-075, recodified as §182-501-0135, filed 6/30/11,
effective 7/1/11. Statutory Authority:
RCW
74.08.090. 10-19-057, § 388-501-0135,
filed 9/14/10, effective 10/15/10. Statutory Authority:
RCW
74.08.090 and
42 C.F.R.
431.51,
431.54(e) and
456.1;
42 U.S.C.
1396 n. 08-05-010, § 388-501-0135, filed
2/7/08, effective 3/9/08. Statutory Authority:
RCW
74.08.090,
74.09.520,
74.04.055, and
42 C.F.R.
431.54. 06-14-062, § 388-501-0135, filed
6/30/06, effective 7/31/06. Statutory Authority:
RCW
74.08.090,
74.04.055, and 42 C.F.R. Subpart B
431.51, 431.54 (e) and (3), and 456.1. 04-01-099, § 388-501-0135, filed
12/16/03, effective 1/16/04. Statutory Authority:
RCW
74.08.090. 01-02-076, § 388-501-0135,
filed 12/29/00, effective 1/29/01. Statutory Authority:
RCW
74.04.050,
74.04.055,
74.04.057 and
74.08.090. 98-16-044, §
388-501-0135, filed 7/31/98, effective 9/1/98. Statutory Authority:
RCW
74.08.090 and
74.09.522. 97-03-038, §
388-501-0135, filed 1/9/97, effective 2/9/97. Statutory Authority:
RCW
74.08.090. 94-10-065 (Order 3732), §
388-501-0135, filed 5/3/94, effective 6/3/94. Formerly WAC
388-81-100.
