Current through Register Vol. 24-18, September 15, 2024
(1)
General.
(a) Providers must
obtain authorization for all covered orally administered or tube-delivered
enteral nutrition products, equipment and related supplies as required in this
chapter, the agency's published billing instructions, and when the clinical
criteria in this chapter are not met.
(b)Authorization does not guarantee
payment.
(c) Authorization
requirements are not a denial of service.
(d)The agency may reject an incomplete
authorization request and return it to the provider for further action. A
returned request is not a denial of service.
(e) If a request for authorization exceeds
limitations in this chapter, the agency evaluates the request under WAC
182-501-0169.
(f) If the agency determines that a service
was wrongfully authorized or did not meet the expedited prior authorization
(EPA) criteria, the agency may recoup payment from the provider under chapters
182-502 and 182-502A WAC.
(g) Upon
request, a provider must furnish documentation to the agency that shows how the
client's condition met the criteria for prior authorization (PA) or
EPA.
(2)Prior
authorization. PA is required for:
(a)
Orally administered enteral nutrition products under WAC
182-554-500; and
(b) Tube-delivered enteral equipment,
replacement parts and related supplies under WAC
182-554-600(3).
(3)
Prior authorization
request form. The provider must submit a request for PA on the Oral
Enteral Nutrition Worksheet Prior Authorization Request form. This form is
available online at http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx. This
form must be:
(a) Complete, with all fields
full;
(b) Completed by the
prescribing physician, advanced registered nurse practitioner, or physician
assistant;
(c) Written, dated, and
signed (including the prescriber's credentials) by the prescriber on the same
day, and before the date of delivery. This form must not be backdated;
and
(d) Submitted within three
months of the date the pre-scriber signed the prescription.
(4)Expedited prior
authorization. For EPA, a provider must establish that the client's
condition meets the clinically appropriate EPA criteria outlined in this
chapter and in the agency's published billing instructions. The provider must
use the appropriate EPA number when billing the agency.
(5) If a fee-for-service client enrolls with
an agency-contracted managed care organization (MCO) before the purchase or
rental of authorized equipment is complete:
(a) The agency stops paying for the equipment
on the last day of the month before the month in which the client enrolls in
the managed care plan; and
(b) The
MCO may reevaluate the client's need for the equipment.
(6) The agency may rescind authorization for
enteral equipment if the client:
(a) Enrolls
in, or becomes eligible for, an MCO;
(b) Becomes covered by a hospice agency and
the equipment is used in the treatment of the terminal diagnosis or related
condition(s);
(c) Loses
eligibility; or
(d) Dies.
11-14-075, recodified as §182-554-700, 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, §
388-554-700, filed 12/21/09, effective 1/21/10. Statutory Authority:
RCW
74.08.090,
74.09.530 and chapter 74.09 RCW.
05-04-059, § 388-554-700, filed 1/28/05, effective
3/1/05.
