Current through Register Vol. 24-18, September 15, 2024
(1)
Eligibility for payment. To
be eligible for payment for covered inpatient hospital services, a hospital
must:
(a) Have a core-provider agreement with
the medicaid agency; and
(b) Be an
in-state hospital, a bordering city hospital, a critical border hospital, or a
distinct unit of that hospital, as defined in WAC
182-550-1050; or
(c) Be an out-of-state hospital that meets
the conditions in WAC
182-550-6700.
(2)
Exclusions. The
agency does not pay for any of the following:
(a) Inpatient care or services, or both,
provided in a hospital or distinct unit to a client when a managed care
organization (MCO) plan is contracted to cover those services.
(b) Care or services, or both, provided in a
hospital or distinct unit provided to a client enrolled in the hospice program,
unless the care or services are completely unrelated to the terminal illness
that qualifies the client for the hospice benefit.
(c) Ancillary services provided in a hospital
or distinct unit unless explicitly spelled out in this chapter.
(d) Additional days of hospitalization on a
non-DRG claim when:
(i) Those days exceed the
number of days established by the agency or the agency's designee under WAC
182-550-2600, as the approved
length of stay (LOS); and
(ii) The
hospital or distinct unit has not received prior authorization for an extended
LOS from the agency or the agency's designee as specified in WAC
182-550-4300(4).
The agency may perform a prospective, concurrent, or retrospective utilization
review as described in WAC
182-550-1700, to evaluate an
extended LOS. An agency designee may also perform those utilization reviews to
evaluate an extended LOS.
(e) Inpatient hospital services when the
agency determines that the client's medical record fails to support the medical
necessity and inpatient level of care for the inpatient admission. The agency
may perform a retrospective utilization review as described in WAC
182-550-1700, to evaluate if the
services are medically necessary and are provided at the appropriate level of
care.
(f) Two separate inpatient
hospitalizations if a client is readmitted to the same or affiliated hospital
or distinct unit within 14 calendar days of discharge and the agency determines
that one inpatient hospitalization does not qualify for a separate payment. See
WAC 182-550-3000
(7)(f) for the agency's review of 14-day
readmissions.
(g) Inpatient claims
for 14-day readmissions considered to be provider preventable as described in
WAC 182-550-2950.
(h) A client's day(s) of absence from the
hospital or distinct unit.
(i) A
nonemergency transfer of a client. See WAC
182-550-3600 for hospital
transfers.
(j) Charges related to a
provider preventable condition (PPC), hospital acquired condition (HAC),
serious reportable event (SRE), or a condition not present on admission (POA).
See WAC 182-502-0022.
(k) An early elective delivery as defined in
WAC 182-500-0030. The agency may pay
for a delivery before 39 weeks gestation, including induction and cesarean
section, if medically necessary under WAC
182-533-0400(20).
(3)
Interim billed inpatient
hospital claims. This section defines when the agency considers payment
for an interim billed inpatient hospital claim.
(a) When the agency is the primary payer,
each interim billed nonpsychiatric claim must:
(i) Be submitted in 60-calendar-day
intervals, unless the client is discharged before the next 60-calendar-day
interval.
(ii) Document the entire
date span between the client's date of admission and the current date of
services billed, and include the following for that date span:
(A) All inpatient hospital services provided;
and
(B) All applicable diagnosis
codes and procedure codes.
(iii) Be submitted as an adjustment to the
previous interim billed hospital claim.
(b) When the agency is not the primary payer:
(i) The agency pays an interim billed
nonpsychiatric claim when the criteria in (a) of this subsection are met;
and
(ii) Either of the following:
(A) Sixty calendar days have passed from the
date the agency became the primary payer; or
(B) A client is eligible for both medicare
and medicaid and has exhausted the medicare lifetime reserve days for inpatient
hospital care.
(c) For psychiatric claims, (a)(i) and (b)(i)
of this subsection do not apply.
(i) When the
agency is the primary payer, each billed psychiatric claim may be submitted in
60-calendar-day intervals unless the client is discharged before the next
60-calendar-day interval.
(ii) If a
claim is submitted under (c)(i) of this subsection, the claim must document the
current dates of services billed and include the following for that date span:
(A) All inpatient hospital services provided;
and
(B) All applicable diagnosis
codes and procedure codes.
(d) When the agency is not the primary payer,
the agency pays a billed psychiatric claim when:
(i) The criteria in (c)(i) of this subsection
are met; and
(ii) Either of the
following occur:
(A) Sixty calendar days have
passed from the date the agency became the primary payer; or
(B) A client is eligible for both medicare
and medicaid and has exhausted the medicare lifetime reserve days for inpatient
hospital care.
(4)
Admission period for claims.
The agency considers for payment a hospital claim submitted for a client's
continuous inpatient hospital admission of 60 calendar days or less upon the
client's formal release from the hospital or distinct unit.
(5)
Billing for hospital claims.
To be eligible for payment, a hospital or distinct unit must bill the agency
using an inpatient hospital claim:
(a) Under
the current national uniform billing data element specifications:
(i) Developed by the National Uniform Billing
Committee (NUBC);
(ii) Approved or
modified, or both, by the Washington state payer group or the agency;
and
(iii) In effect on the date of
the client's admission.
(b) Under the current published international
classification of diseases clinical modification coding guidelines;
(c) Subject to the rules in this section and
other applicable rules;
(d) Under
the agency's published billing instructions and other documents; and
(e) With the date span that covers the
client's entire hospitalization. See subsection (3) of this section for when
the agency considers and pays an initial interim billed hospital claim and any
subsequent interim billed hospital claims;
(f) That requires an adjustment due to, but
not limited to, charges that were not billed on the original paid claim (e.g.,
late charges), through submission of an adjusted hospital claim. Each
adjustment to a paid hospital claim must provide complete documentation for the
entire date span between the client's admission date and discharge date, and
include the following for that date span:
(i)
All inpatient hospital services provided; and
(ii) All applicable diagnosis codes and
procedure codes; and
(g)
With the appropriate NUBC revenue code specific to the service or treatment
provided to the client.
(6)
Multiple hospital rates.
When a hospital charges multiple rates for an accommodation room and board
revenue code, the agency pays the hospital's lowest room and board rate for
that revenue code. The agency may request the hospital's charge master. Room
charges must not exceed the hospital's usual and customary charges to the
general public, as required by
42 C.F.R. Sec.
447.271.
(7)
Administrative day rate. The
agency allows hospitals an administrative day rate for those days of a hospital
stay in which a client no longer meets criteria for the acute inpatient level
of care, as provided in WAC
182-550-4550.
(8)
Payment for observation
services. The agency pays for observation services according to WAC
182-550-6000,
182-550-7200, and other
applicable rules.
(9)
Required adjustments. The agency determines its actual payment for
an inpatient hospital admission by making any required adjustments from the
calculations of the allowed covered charges. Adjustments include:
(a) Client participation (e.g.,
spenddown);
(b) Any third-party
liability amount, including medicare part A and part B; and
(c) Any other adjustments as determined by
the agency.
(10)
Clients under state-administered programs. The agency pays
hospitals less for services provided to clients eligible under
state-administered programs, as provided in WAC
182-550-4800.
(11)
Final charges. All hospital
providers must present final charges to the agency according to WAC
182-502-0150.
11-14-075, recodified as §182-550-2900, filed 6/30/11,
effective 7/1/11. Statutory Authority:
RCW
74.08.090 and
74.09.500. 07-14-055, §
388-550-2900, filed 6/28/07, effective 8/1/07; 04-20-058, § 388-550-2900,
filed 10/1/04, effective 11/1/04. Statutory Authority:
RCW
74.08.090 and
42 U.S.C.
1395 x(v),
42 C.F.R.
447.271, .11303, and .2652. 01-16-142, §
388-550-2900, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW
74.09.090, 42 U.S.C.
1395 x(v) and 1396r-4,
42 C.F.R.
447.271, 11303 and 2652. 99-14-027, §
388-550-2900, filed 6/28/99, effective 7/1/99. Statutory Authority:
RCW
74.08.090,
42 USC
1395 x(v),
42 C.F.R.
447.271, 447.11303, and 447.2652. 99-06-046,
§ 388-550-2900, filed 2/26/99, effective 3/29/99. Statutory Authority:
RCW
74.08.090,
74.09.730,
74.04.050,
70.01.010,
74.09.200,[74.09.]500 ,
[74.09.]530 and 43.20B.020. 98-01-124, § 388-550-2900, filed 12/18/97,
effective 1/18/98.
