Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-501 - Administration of medical programs-General
Section 182-501-0182 - Health care provided in another state or U.S. territory - Nonemergency

(1) This rule applies to nonemergency treatment situations occurring in another state or U.S. territory. Applicable situations include, but are not limited to:

(2) Under the prior authorization process described in WAC 182-501-0165, except as specified in subsection (3) of this section, the agency pays for covered nonemergency health care services provided to an eligible Washington apple health (WAH) recipient in another state or U.S. territory to the same extent that it pays for covered nonemergency services provided within the state of Washington when the agency determines that:

(3) The agency pays for covered nonemergency health care services for an eligible WAH recipient in another state or U.S. territory, unless the out-of-state provider will not accept the agency's payment as payment in full under 42 C.F.R. 447.15. The agency does not pay when the provider refuses to accept the agency's payment as payment in full.

(4) The agency does not pay for medically necessary, nonsymptomatic treatment (i.e., preventive care) furnished outside the state of Washington unless it is furnished in a designated bordering city, which is considered the same as an in-state city for the purposes of health care coverage (see WAC 182-501-0175) . Covered nonemergency services requiring prior authorization, when provided in the state of Washington, also require prior authorization, when provided in a designated bordering city (see WAC 182-501-0165 for the agency's medical necessity determination process).

(5)See WAC 182-501-0180 for additional information regarding health care services provided outside the state of Washington.

(6) The agency's director or designee reviews all exception to rule (ETR) requests.