Current through Register Vol. 24-18, September 15, 2024
(1) The purpose
of this section is to specify the limited circumstances in which:
(a) Fee-for-service or managed care clients
can choose to self-pay for medical assistance services; and
(b) Providers (as defined in WAC
182-500-0085
) have the authority to bill fee-for-service or managed care clients for
medical assistance services furnished to those clients.
(2) The provider is responsible for:
(a) Verifying whether the client is eligible
to receive medical assistance services on the date the services are
provided;
(b) Verifying whether the
client is enrolled with a medicaid agency-contracted managed care organization
(MCO);
(c) Knowing the limitations
of the services within the scope of the eligible client's medical program (see
WAC
182-501-0050(4)(a)
and
182-501-0065
);
(d) Informing the client of
those limitations;
(e) Exhausting
all applicable medicaid agency or agency-contracted MCO processes necessary to
obtain authorization for requested service(s);
(f) Ensuring that translation or
interpretation is provided to clients with limited English proficiency (LEP)
who agree to be billed for services in accordance with this section;
and
(g) Retaining all documentation
which demonstrates compliance with this section.
(3) Unless otherwise specified in this
section, providers must accept as payment in full the amount paid by the agency
or agency-contracted MCO for medical assistance services furnished to clients.
See
42 C.F.R. §
447.15.
(4) A provider must not bill a client, or
anyone on the client's behalf, for any services until the provider has
completed all requirements of this section, including the conditions of payment
described in the agency's rules, the agency's fee-for-service billing
instructions, and the requirements for billing the agency-contracted MCO in
which the client is enrolled, and until the provider has then fully informed
the client of his or her covered options. A provider must not bill a client
for:
(a) Any services for which the provider
failed to satisfy the conditions of payment described in the agency's rules,
the agency's fee-for-service billing instructions, and the requirements for
billing the agency-contracted MCO in which the client is enrolled.
(b) A covered service even if the provider
has not received payment from the agency or the client's MCO.
(c) A covered service when the agency or its
designee denies an authorization request for the service because the required
information was not received from the provider or the prescriber under WAC
182-501-0165(7)(c)(i).
(5) If the requirements of this
section are satisfied, then a provider may bill a fee-for-service or a managed
care client for a covered service, defined in WAC
182-501-0050(9),
or a noncovered service, defined in WAC
182-501-0050(10)
and
182-501-0070.
The client and provider must sign and date the HCA form 13-879, Agreement to
Pay for Healthcare Services, before the service is furnished. Form 13-879,
including translated versions, is available to download at
http://hrsa.dshs.wa.gov/mpforms.shtml. The requirements for this subsection are
as follows:
(a) The agreement must:
(i) Indicate the anticipated date the service
will be provided, which must be no later than ninety calendar days from the
date of the signed agreement;
(ii)
List each of the services that will be furnished;
(iii) List treatment alternatives that may
have been covered by the agency or agency-contracted MCO;
(iv) Specify the total amount the client must
pay for the service;
(v) Specify
what items or services are included in this amount (such as preoperative care
and postoperative care). See WAC
182-501-0070(3)
for payment of ancillary services for a noncovered service;
(vi) Indicate that the client has been fully
informed of all available medically appropriate treatment, including services
that may be paid for by the agency or agency-contracted MCO, and that he or she
chooses to get the specified service(s);
(vii) Specify that the client may request an
exception to rule (ETR) in accordance with WAC
182-501-0160
when the agency or its designee denies a request for a noncovered service and
that the client may choose not to do so;
(viii) Specify that the client may request an
administrative hearing in accordance with chapter 182-526 WAC to appeal the
agency's or its designee denial of a request for prior authorization of a
covered service and that the client may choose not to do so;
(ix) Be completed only after the provider and
the client have exhausted all applicable agency or agency-contracted MCO
processes necessary to obtain authorization of the requested service, except
that the client may choose not to request an ETR or an administrative hearing
regarding agency or agency designee denials of authorization for requested
service(s); and
(x) Specify which
reason in subsection (b) below applies.
(b) The provider must select on the agreement
form one of the following reasons (as applicable) why the client is agreeing to
be billed for the service(s). The service(s) is:
(i) Not covered by the agency or the client's
agency-contracted MCO and the ETR process as described in WAC
182-501-0160
has been exhausted and the service(s) is denied;
(ii) Not covered by the agency or the
client's agency-contracted MCO and the client has been informed of his or her
right to an ETR and has chosen not to pursue an ETR as described in WAC
182-501-0160;
(iii) Covered by the agency or the client's
agency-contracted MCO, requires authorization, and the provider completes all
the necessary requirements; however the agency or its designee denied the
service as not medically necessary (this includes services denied as a
limitation extension under WAC
182-501-0169
); or
(iv) Covered by the agency or
the client's agency-contracted MCO and does not require authorization, but the
client has requested a specific type of treatment, supply, or equipment based
on personal preference which the agency or MCO does not pay for and the
specific type is not medically necessary for the client.
(c) For clients with limited English
proficiency, the agreement must be the version translated in the client's
primary language and interpreted if necessary. If the agreement is translated,
the interpreter must also sign it;
(d) The provider must give the client a copy
of the agreement and maintain the original and all documentation which supports
compliance with this section in the client's file for six years from the date
of service. The agreement must be made available to the agency or its designee
for review upon request; and
(e) If
the service is not provided within ninety calendar days of the signed
agreement, a new agreement must be completed by the provider and signed by both
the provider and the client.
(6) There are limited circumstances in which
a provider may bill a client without executing form 13-879, Agreement to Pay
for Healthcare Services, as specified in subsection (5) of this section. The
following are those circumstances:
(a) The
client, the client's legal guardian, or the client's legal representative:
(i) Was reimbursed for the service directly
by a third party (see WAC
182-501-0200
); or
(ii) Refused to complete and
sign insurance forms, billing documents, or other forms necessary for the
provider to bill the third party insurance carrier for the service.
(b) The client represented
himself/herself as a private pay client and not receiving medical assistance
when the client was already eligible for and receiving benefits under a medical
assistance program. In this circumstance, the provider must:
(i) Keep documentation of the client's
declaration of medical coverage. The client's declaration must be signed and
dated by the client, the client's legal guardian, or the client's legal
representative; and
(ii) Give a
copy of the document to the client and maintain the original for six years from
the date of service, for agency or the agency's designee review upon
request.
(c) The bill
counts toward the financial obligation of the client or applicant (such as
spenddown liability, client participation as described in chapters 182-513 and
182-515 WAC, emergency medical expense requirement, deductible, or copayment
required by the agency or its designee). See subsection (7) of this section for
billing a medically needy client for spenddown liability;
(d) The client is placed in the agency's or
an agency-contracted MCO's patient review and coordination (PRC) program and
obtains nonemergency services from a nonpharmacy provider that is not an
assigned or appropriately referred provider as described in WAC
182-501-0135;
(e) The client is a dual-eligible client with
medicare Part D coverage or similar creditable prescription drug coverage and
the conditions of WAC
182-530-7700(2)(a)(iii)
are met;
(f) The service is within
a service category excluded from the client's benefits package. See WAC
182-501-0060;
(g) The services were noncovered ambulance
services (see WAC
182-546-0250(2)
);
(h) A fee-for-service client
chooses to receive nonemergency services from a provider who is not contracted
with the agency or its designee after being informed by the provider that he or
she is not contracted with the agency or its designee and that the services
offered will not be paid by the client's health care program; and
(i) An agency-contracted MCO enrollee chooses
to receive nonemergency services from providers outside of the MCO's network
without authorization from the MCO, i.e., a nonparticipating
provider.
(7) Under
chapter 182-519 WAC, an individual who has applied for medical assistance is
required to spend down excess income on health care expenses to become eligible
for coverage under the medically needy program. An individual must incur health
care expenses greater than or equal to the amount that he or she must spend
down. The provider is prohibited from billing the individual for any amount in
excess of the spenddown liability assigned to the bill.
(8) There are situations in which a provider
must refund the full amount of a payment previously received from or on behalf
of an individual and then bill the agency for the covered service that had been
furnished. In these situations, the individual becomes eligible for a covered
service that had already been furnished. Providers must then accept as payment
in full the amount paid by the agency or its designee or managed care
organization for medical assistance services furnished to clients. These
situations are as follows:
(a) The individual
was not receiving medical assistance on the day the service was furnished. The
individual applies for medical assistance later in the same month in which the
service was provided and the agency or its designee makes the individual
eligible for medical assistance from the first day of that month;
(b) The client receives a delayed
certification for medical assistance as defined in WAC
182-500-0025;
or
(c) The client receives a
certification for medical assistance for a retroactive period according to
42 C.F.R. §
435.914(a) and defined in
WAC
182-500-0095.
(9) Regardless of any written,
signed agreement to pay, a provider may not bill, demand, collect, or accept
payment or a deposit from a client, anyone on the client's behalf, or the
agency or its designee for:
(a) Copying,
printing, or otherwise transferring health care information, as the term health
care information is defined in chapter 70.02 RCW, to another health care
provider. This includes, but is not limited to:
(i) Medical/dental charts;
(ii) Radiological or imaging films;
and
(iii) Laboratory or other
diagnostic test results.
(b) Missed, canceled, or late
appointments;
(c) Shipping and/or
postage charges;
(d) "Boutique,"
"concierge," or enhanced service packages (e.g., newsletters, 24/7 access to
provider, health seminars) as a condition for access to care; or
(e) The price differential between an
authorized service or item and an "upgraded" service or item (e.g., a
wheelchair with more features; brand name versus generic drugs).
Statutory Authority:
RCW
41.05.021 and section 1927 of the Social
Security Act. WSR 12-18-062, §182-502-0160, filed 8/31/12, effective
10/1/12. WSR 11-14-075, recodified as §182-502-0160, filed 6/30/11,
effective 7/1/11. Statutory Authority:
RCW
74.08.090. WSR 10-19-057, §
388-502-0160, filed 9/14/10, effective 10/15/10. Statutory Authority:
RCW
74.08.090 and
42 C.F.R.
447.15. WSR 10-10-022, § 388-502-0160,
filed 4/26/10, effective 5/27/10. Statutory Authority:
RCW
74.08.090,
74.09.055, 2001 c 7, Part II. WSR
02-12-070, § 388-502-0160, filed 5/31/02, effective 7/1/02. Statutory
Authority:
RCW
74.08.090. WSR 01-21-023, §
388-502-0160, filed 10/8/01, effective 11/8/01; WSR 01-05-100, §
388-502-0160, filed 2/20/01, effective 3/23/01. Statutory Authority:
RCW
74.08.090 and
74.09.520. WSR 00-14-069, §
388-502-0160, filed 7/5/00, effective
8/5/00.
