WAC 388-501-0169   Healthcare coverage -- Limitation extension.  This section addresses requests for limitation extensions (additional covered services when a client has received the maximum services allowed under specific healthcare program rules). The department does not pay for services exceeding the maximum allowed until authorization is obtained.

     (1) No extension of covered services will be authorized when prohibited by specific program rules.

     (2) When an extension is not prohibited by specific program rules, a client or the client's provider may request a limitation extension.

     (3) Under fee-for-service (FFS), the department evaluates requests for limitation extensions using the process described in WAC 388-501-0165. For a managed care enrollee, the client's managed care organization (MCO) evaluates requests for limitation extensions according to the MCO's prior authorization process.

     (4) In addition to subsection (3), both the department and MCO consider the following in evaluating a request for a limitation extension:

     (a) The level of improvement the client has shown to date related to the requested service and the reasonably calculated probability of continued improvement if the requested service is extended; and

     (b) The reasonably calculated probability the client's condition will worsen if the requested service is not extended.



[Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-501-0169, filed 11/30/06, effective 1/1/07.]