Current through Register Vol. 24-18, September 15, 2024
(1)
General. The agency covers tube-delivered enteral nutrition
products, equipment, and related supplies, regardless of age if the client:
(a) Has a valid prescription under WAC
182-554-400, which must be
submitted within three months of the date the prescriber signed the
prescription;
(b) Can manage tube
feedings :
(i) Independently; or
(ii) With a caregiver's assistance;
and
(c) Has at least one
of the following medical conditions:
(i) A
disease or condition that impairs the client's ability to ingest sufficient
calories and nutrients or restricts calories and nutrients from reaching the
client's gastrointestinal tract; or
(ii) A disease or condition of the small
bowel that impairs digestion and absorption of an oral diet, either of which
requires tube feedings to provide sufficient nutrients to maintain weight and
strength that is properly proportioned to the client's overall health
status.
(2)
Limitations. The following limitations apply to the agency's
payment for covered tube-delivered enteral nutrition products, equipment and
related supplies. The agency pays for:
(a)
One purchased pump, per client, in a five-year period;
(b) One purchased nondisposable intravenous
pole required for enteral nutrition product delivery, per client, per lifetime;
and
(c) No more than twelve months
of equipment rental. After twelve months the agency considers the equipment
purchased and it becomes the client's property.
(3)
Women, infants, and children (WIC)
program.
(a) If the client is age four
or younger, the client must have a signed and dated written notification from
the WIC program to receive tube delivered enteral nutrition products. The
notice must verify:
(i) The client is not
eligible for the WIC program; or
(ii) The client is eligible for the WIC
program, but the client's need for a tube delivered enteral nutrition product
exceeds WIC's allowed amount.
(b) If the client is age four or younger and
is unable to receive a necessary tube delivered enteral nutrition product from
WIC, the provider must keep the following information in the client's file:
(i) Documentation that the requested tube
delivered product is not available through the WIC program; or
(ii) Reasons why a similar WIC product does
not meet the client's needs.
(4)
Authorization.
(a) If the client meets the criteria in
subsection (1) of this section, the provider must follow the agency's expedited
prior authorization (EPA) process to receive payment.
(b) If the client does not meet the criteria
in subsection (1) of this section, the provider must submit a request for prior
authorization (PA). The PA request must meet the requirements under WAC
182-554-700(3).
(c) The agency pays for enteral equipment
replacement parts with PA if the equipment is:
(i) Owned by the client;
(ii) Less than five years old; and
(iii) No longer under warranty.
11-14-075, recodified as §182-554-600, filed 6/30/11,
effective 7/1/11. Statutory Authority: 2009 c 564 § 1109,
RCW
74.04.050, and
74.08.090. 10-01-138, §
388-554-600, filed 12/21/09, effective 1/21/10. Statutory Authority:
RCW
74.04.050,
74.08.090,
74.09.530, and
74.09.700. 06-24-036, §
388-554-600, filed 11/30/06, effective 1/1/07. Statutory Authority:
RCW
74.08.090,
74.09.530 and chapter 74.09 RCW.
05-04-059, § 388-554-600, filed 1/28/05, effective
3/1/05.
