Current through Register Vol. 24-18, September 15, 2024
(1) A
client receiving services provided under fee-for-service or through a medicaid
agency-contracted managed care organization (MCO) may be transported to a local
provider only.
(a) A local provider's medical
specialty may vary as long as the provider is capable of providing medically
necessary care that is the subject of the appointment or treatment;
(b) A provider may be considered an available
local provider if:
(i) Providers in the
client's local community are not accepting medicaid clients; or
(ii) Providers in the client's local
community are not contracted with the client's MCO, primary care case
management group, or third-party coverage.
(2) Brokers are responsible for considering
and authorizing exceptions. See subsection (3) of this section for
exceptions.
(3) A broker may
transport a client to a provider outside the client's local community for
covered health care services when any of the following apply:
(a) The health care service is not available
within the client's local community.
(i) If
requested by the broker, the client or the client's provider must provide
documentation from the client's primary care provider (PCP), specialist, or
other appropriate provider verifying the medical necessity for the client to be
served by a health care provider outside of the client's local
community.
(ii) If the service is
not available in the client's local community, the broker may authorize
transportation to the nearest provider where the service may be
obtained;
(b) The
transportation to a provider outside the client's local community is required
for continuity of care.
(i) If requested by
the broker, the client or the client's provider must submit documentation from
the client's PCP, specialist, or other appropriate provider verifying the
existence of ongoing treatment for medically necessary care by the provider and
the medical necessity for the client to continue to be served by the health
care provider.
(ii) If the broker
authorizes transportation to a provider outside the client's local community
based on continuity of care, this authorization is for a limited period of time
for completion of ongoing care for a specific medical condition. Each transport
must be related to the ongoing treatment of the specific condition that
requires continuity of care.
(iii)
Ongoing treatment of medical conditions that may qualify for transportation
based on continuity of care include, but are not limited to:
(A) Active cancer treatment;
(B) Recent transplant (within the last twelve
months);
(C) Scheduled surgery
(within the next sixty days);
(D)
Major surgery (within the previous ninety days); or
(E) Third trimester of pregnancy;
(c) The health care
service is paid by a third-party payer who requires or refers the client to a
specific provider within their network;
(d) The total cost to the agency, including
transportation costs, is lower when the health care service is obtained outside
of the client's local community; and
(e) A provider outside the client's local
community has been issued a global payment by the agency for services the
client will receive, and the broker determines it to be cost effective to
provide transportation for the client to complete treatment with this
provider.
(4) Brokers
determine whether an exception should be granted based on documentation from
the client's health care providers and program rules.
(5) When a client or a provider moves to a
new community, the existence of a provider-client relationship, independent of
other factors, does not constitute a medical need for the broker to authorize
and pay for transportation to the previous provider.
(6) The health care service must be provided
in the state of Washington or a designated border city, unless the agency
specifically authorizes transportation to an out-of-state provider in
accordance with WAC
182-546-5800.
(7) If local Washington apple health
providers refuse to see a client due to the client's noncompliance, the agency
does not authorize or pay more for nonemergency transportation to a provider
outside the client's local community.
(a) In
this circumstance, the agency pays for the least costly, most appropriate, mode
of transportation from one of the following options:
(i) Transit bus fare;
(ii) Commercial bus or train fare;
(iii) Gas voucher/gas card; or
(iv) Mileage reimbursement.
(b) The agency's payment, whether
fare, tickets, voucher, or mileage reimbursement, is determined using the
number of miles from the client's authorized pickup point (e.g., client
residence) to the location of the local health care provider who otherwise
would have been available if not for the client's noncompliance.
(8) The agency may grant an
exception to subsection (7) of this section for a life-sustaining service or as
reviewed and authorized by the agency's medical director or designee in
accordance with WAC
182-502-0050 and
182-502-0270.
11-17-032, recodified as WAC 182-546-5700, filed 8/9/11,
effective 8/9/11. Statutory Authority:
RCW
74.04.057,
74.08.090, and
74.09.500. 11-15-029, §
388-546-5700, filed 7/12/11, effective
8/12/11.
