Section 182-502-0100 - General conditions of payment(1) The medic-aid agency pays for health care services furnished to an eligible client when the claim satisfies agency rules including all the following: (a) The service is within the scope of care of the client's Washington apple health program;(b) The service is medically necessary;(c) The service is properly authorized;(d) The provider bills within the time frame set in WAC 182-502-0150;(e) The provider bills according to agency rules and billing instructions; and(f) The provider follows third-party payment procedures.(2) The agency pays for health care services only when the services are provided by or on behalf of a provider that is enrolled with the agency.(3) In order for any services or supplies ordered, prescribed, or referred by a provider to be paid: (a) The provider must be enrolled with the agency under their national provider identifier (NPI); and(b) The NPI for the referring, prescribing, or ordering provider must be included on the claim form.(4) If payment for services is to be made to a group practice, partnership, or corporation, the group, partnership, or corporation must enroll with the agency and provide its national provider identifier (NPI) (if eligible for an NPI) to be used for submitting claims as the billing provider.(5) The agency is the payer of last resort, unless the other payer is: (a) An Indian health service;(b) A crime victims program through the department of labor and industries; or(c) A school district for health services provided under the Individuals with Disabilities Education Act.(6) The agency does not pay providers for health care services identified by the agency as client financial obligations, and deducts from the payment the costs of those services identified as client financial obligations. Client financial obligations include, but are not limited to, the following: (a) Copayments (copays) (unless the criteria in chapter 182-517 WAC or WAC 182-501-0200 are met);(b) Deductibles (unless the criteria in chapter 182-517 WAC or WAC 182-501-0200 are met); and(c) Spenddown (see WAC 182-519-0110).(7) The agency does not pay for any health care service, drug, supply, or equipment prescribed or ordered by a health care professional, health care entity, supplier, or contractor of service not currently enrolled with the agency.(8) The agency does not pay for services provided to clients during the application process for provider enrollment, regardless of whether the agency later approves or denies the application, unless an exception for earlier enrollment is approved by the agency in accordance with WAC 182-502-0005.(9) The agency does not pay for any health care service, drug, supply, or equipment prescribed or ordered by a health care professional, health care entity, supplier, or contractor of services whose application for enrollment has been denied or terminated.(10) The provider must accept medicare assignment for claims involving clients eligible for both medicare and Washington apple health before the agency makes any payment.(11) The provider is responsible for verifying whether a client has Washington apple health coverage for the dates of service.(12) The agency may reimburse a provider for services provided to a person if it is later determined that the person was ineligible for the service when it was provided if:(a) The agency considered the person eligible at the time of service;(b) The service was not otherwise paid for; and(c) The provider submits a request for payment to the agency.(13) The agency does not pay on a fee-for-service basis for a service for a client who is enrolled in a managed care plan when the service is included in the plan's contract with the agency.(14) Information about health care services for jail inmates is found in RCW 70.48.130.(15) The agency pays for medically necessary services on the basis of usual and customary charges or the maximum allowable fee established by the agency, whichever is lower.Wash. Admin. Code § 182-502-0100
Amended by WSR 15-14-039, Filed 6/24/2015, effective 7/25/2015Amended by WSR 23-24-026, Filed 11/29/2023, effective 1/1/2024Amended by WSR 24-23-009, Filed 11/8/2024, effective 12/9/202411-14-075, recodified as §182-502-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. 11-11-014, § 388-502-0100, filed 5/9/11, effective 6/9/11; 10-19-057, § 388-502-0100, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 71.05.560, 74.04.050, 74.04.057, 74.08.090, 74.09.500, 74.09.530. 06-13-042, § 388-502-0100, filed 6/15/06, effective 7/16/06. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.530. 00-15-050, § 388-502-0100, filed 7/17/00, effective 8/17/00.