Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-538 - Managed care
Section 182-538-096 - Scope of service for PCCM enrollees
Universal Citation: WA Admin Code 182-538-096
Current through Register Vol. 24-18, September 15, 2024
(1) An enrollee is entitled to timely access to covered services that are medically necessary.
(2) A primary care case management (PCCM) enrollee is eligible for the scope of services that are covered based on the enrollee's apple health eligibility program. See WAC 182-501-0060 and 182-501-0065 for categories of services that are covered and program rules for specific services that are covered.
(3) The agency covers services through the fee-for-service system for enrollees with a primary care case management (PCCM) provider.
(a) The PCCM provider must either provide the
covered services or refer the enrollee to other providers who are contracted
with the agency for covered services, except for emergency services.
(b) The PCCM provider is responsible for
explaining to the enrollee how to obtain the services for which the PCCM
provider is referring the enrollee.
(c) Services that require PCCM provider
referral are described in the PCCM contract.
(d) The agency sends each enrollee written
information about covered services when the client enrolls in managed care and
when there is a change in covered services. This information describes covered
services, which services are covered by the agency, and how to access services
through the PCCM provider.
(4) The agency will not authorize or pay for the following services :
(a) Services that
are not medically necessary as defined in WAC
182-500-0070.
(b) Services not included in the scope of
covered services for the client's apple health eligibility program.
(c) Services received in a hospital emergency
department for nonemergency medical conditions, other than a screening exam as
described in WAC
182-538-100(3).
Disclaimer: These regulations may not be the most recent version. Washington may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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