Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-502 - Administration of medical programs-Providers
ENROLLMENT
Section 182-502-0006 - Enrollment for nonbilling individual providers
Universal Citation: WA Admin Code 182-502-0006
Current through Register Vol. 24-18, September 15, 2024
(1) The agency pays for health care services, drugs, supplies or equipment prescribed, ordered, or referred by a health care professional only when the health care professional has one of the following approved agreements with the agency and all other conditions of payment have been met (see WAC 182-501-0050) :
(a) Core provider agreement, in accordance
with WAC 182-502-0005; or
(b) Nonbilling provider agreement, in
accordance with subsection (4) of this section.
(2) Only a licensed health care professional whose scope of practice under their licensure includes ordering, prescribing, or referring may enroll as a nonbilling provider.
(3) Nothing in this chapter obligates the agency to enroll any health care professional who requests enrollment as a nonbilling provider.
(4) Enrollment.
(a) To enroll as a
nonbilling provider with the medicaid agency, a health care professional must,
on the date of application:
(i) Not already be
enrolled with the medicaid agency as a billing or servicing provider;
(ii) Be currently licensed, certified,
accredited, or registered according to Washington state laws and
rules;
(iii) Be enrolled with
medicare, when required in specific program rules;
(iv) Have current professional liability
coverage, individually or as a member of a group, to the extent the health care
professional is not covered by the Federal Tort Claims Act, including related
rules and regulations;
(v) Have a
current federal drug enforcement agency (DEA) certificate, if applicable to the
profession's scope of practice;
(vi) Pass the agency's screening process,
including license verifications, data base checks, site visits, and criminal
background checks, including fingerprint-based criminal background checks as
required by 42 C.F.R.
455.434 if considered high-risk under
42 C.F.R.
455.450. The agency uses the same screening
level risk categories that apply under medicare. For those provider types that
are not recognized under medicare, the agency assesses the risk of fraud,
waste, and abuse using similar criteria to those used in medicare;
(vii) Meet the conditions in this chapter and
other chapters regulating the specific type of health care practitioner;
and
(viii) Sign, without
modification, a Medicaid Enrollment Application and Agreement for Nonbilling
Individual Providers form (HCA 13-002). The medicaid agency and each provider
signing a Medicaid Enrollment Application and Agreement for Nonbilling
Individual Providers form (HCA 13-002) will hold each other harmless from a
legal action based on the negligent actions or omissions of either party under
the terms of this agreement.
(b) The medicaid agency does not enroll a
nonbilling provider for reasons which include, but are not limited to, the
following:
(i) The agency determines that:
(A) There is a quality of care issue with
significant risk factors that may endanger client health and/or safety (see WAC
182-502-0030(1)(a)
); or
(B) There are risk factors that affect the
credibility, honesty, or veracity of the health care practitioner (see WAC
182-502-0030(1)(b)
) .
(ii) The health care professional:
(A) Is excluded from participation in
medicare, medicaid or any other federally funded health care program;
(B) Has a current formal or informal pending
disciplinary action, statement of charges, or the equivalent from any state or
federal professional disciplinary body at the time of initial
application;
(C) Has a suspended,
terminated, revoked, or surrendered professional license as defined under
chapter 18.130 RCW;
(D) Has a
restricted, suspended, terminated, revoked, or surrendered professional license
in any state;
(E) Is noncompliant
with the department of health's or other state health care agency's stipulation
of informal disposition, agreed order, final order, or similar licensure
restriction;
(F) Is suspended or
terminated by any agency within the state of Washington that arranges for the
provision of health care;
(G) Fails
a background check, including a fingerprint-based criminal background check,
performed by the agency. See WAC
182-502-0014, except that
subsection (2) of this section does not apply to nonbilling
providers;
(H) Does not have
sufficient liability insurance according to (a) (iv) of this subsection for the
scope of practice, to the extent the health care professional is not covered by
the Federal Tort Claims Act, including related rules and regulations;
or
(I) Fails to meet the
requirements of a site visit, as required by
42 C.F.R.
455.432.
(5) Effective date of enrollment of nonbilling provider. Enrollment of a nonbilling provider applicant is effective on the date the agency approves the nonbilling provider application.
(a) A nonbilling provider
applicant may ask for an effective date earlier than the agency's approval of
the nonbilling provider application by submitting a written request to the
agency's chief medical officer. The request must specify the requested
effective date and include an explanation justifying the earlier effective
date. The chief medical officer will not authorize an effective date that is:
(i) Earlier than the effective date of any
required license or certification; or
(ii) More than three hundred sixty-five days
prior to the agency's approval of the nonbilling provider
application.
(b) The
chief medical officer or designee may approve exceptions as follows:
(i) Emergency services;
(ii) Agency-approved out-of-state services;
(iii) Medicaid provider entities
that are subject to survey and certification by CMS or the state survey agency;
(iv) Retroactive client
eligibility; or
(v) Other critical
agency need as determined by the agency's chief medical officer or
designee.
(6) Continuing requirements. To continue eligibility, a nonbilling provider must:
(a) Only order, refer, or
prescribe for clients consistent with the scope of their department of health
(DOH) licensure and agency program rules;
(b) Provide all services without
discriminating on the grounds of race, creed, color, age, sex, sexual
orientation, religion, national origin, marital status, the presence of any
sensory, mental or physical handicap, or the use of a trained dog guide or
service animal by a person with a disability;
(c) Document that the client was informed
that the provider:
(i) May bill the client for
any billable item or service. The rules in WAC
182-502-0160 do not apply;
and
(ii) Is enrolled with the
agency for the sole purpose of ordering, prescribing, or referring items or
services for clients.
(d) Inform the agency of any changes to the
provider's Medicaid Enrollment Application and Agreement for Non-billing
Individual Providers form (HCA 13-002) including, but not limited to, changes
in:
(i) Address or telephone number;
(ii) Business name.
(e) Retain a current professional
state license, registration, certification and applicable business license for
the service being provided, and update the agency of all changes;
(f) Inform the agency in writing within seven
business days of receiving any informal or formal disciplinary order, decision,
disciplinary action or other action(s) including, but not limited to,
restrictions, limitations, conditions and suspensions resulting from the
practitioner's acts, omissions, or conduct against the provider's license,
registration, or certification in any state;
(g) Maintain professional liability coverage
requirements, to the extent the nonbilling provider is not covered by the
Federal Tort Claims Act, including related rules and regulations;
(h) Not surrender, voluntarily or
involuntarily, his or her professional state license, registration, or
certification in any state while under investigation by that state or due to
findings by that state resulting from the practitioner's acts, omissions, or
conduct;
(i) Furnish documentation
or other assurances as determined by the agency in cases where a provider has
an alcohol or chemical dependency problem, to adequately safeguard the health
and safety of medical assistance clients that the provider:
(i) Is complying with all conditions,
limitations, or restrictions to the provider's practice both public and
private; and
(ii) Is receiving
treatment adequate to ensure that the dependency problem will not affect the
quality of the provider's practice.
(j) Submit to a revalidation process at least
every five years. This process includes, but is not limited to:
(i) Updating provider information;
(ii) Submitting forms as required by the
agency including, but not limited to, a new Medicaid Enrollment Application and
Agreement for Nonbilling Individual Providers form (HCA 13-002); and
(iii) Passing the agency's screening process
as specified in subsection (4)(a)(vi) of this section.
(k) Follow the laws and rules that govern the
agency's programs. A nonbilling provider may contact the agency with questions
regarding the agency's programs. However, the agency's response is based solely
on the information provided to the agency's representative at the time of
inquiry, and in no way exempts a nonbilling provider from this
requirement.
(7) Audit or investigation.
(a)
Audits or investigations may be conducted to determine compliance with the rule
and regulations of the program.
(b)
If an audit or investigation is initiated, the provider must retain all
original records and supportive materials until the audit is completed and all
issues are resolved even if the period of retention extends beyond the required
six year period.
(8) Inspection; maintenance of records. For six years from the date of services, or longer if required specifically by law, the nonbilling provider must:
(a) Keep complete and accurate medical
records that fully justify and disclose the extent of the services or items
ordered, referred or prescribed.
(b) Make available upon request appropriate
documentation, including client records, supporting material for review by the
professional staff within the agency or the U.S. Department of Health and Human
Services. The nonbilling provider understands that failure to submit or failure
to retain adequate documentation may result in the termination of the
nonbilling provider's enrollment.
(9) Terminations.
(a) The agency may immediately terminate a
nonbilling provider's agreement, and refer the nonbilling provider to the
appropriate state health professions quality assurance commission for:
(i) Any of the reasons in WAC
182-502-0030 termination for
cause (except that subsection (1)(a)(ix) and (b)(i) do not apply);
and
(ii) Failure to comply with the
requirements of subsections (4), (6), and (8) of this section.
(b) Either the agency or the
provider may terminate this agreement for convenience at any time with thirty
calendar days' written notification to the other.
(c) If this agreement is terminated for any
reason, the agency will pay for services ordered, referred, or prescribed by
the provider only through the date of termination.
(10) Termination disputes.
(a) To dispute terminations of a nonbilling
provider agreement under subsection (9)(a) of this section, the dispute process
in WAC 182-502-0050 applies.
(b) Nonbilling providers cannot dispute
terminations under subsection (9)(b) of this section.
Statutory Authority: 42 C.F.R. 455.410, RCW 41.05.021. WSR 13-19-037, §182-502-0006, filed 9/11/13, effective 10/12/13. WSR 13-18-003, §182-502-0006, filed 8/21/2013, effective 9/21/2013
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