WAC 388-502-0100   General conditions of payment.  (1) The department reimburses for medical services furnished to an eligible client when all of the following apply:

     (a) The service is within the scope of care of the client's medical assistance program;

     (b) The service is medically or dentally necessary;

     (c) The service is properly authorized;

     (d) The provider bills within the time frame set in WAC 388-502-0150;

     (e) The provider bills according to department rules and billing instructions; and

     (f) The provider follows third-party payment procedures.

     (2) The department 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.

     (3) The department does not reimburse providers for medical services identified by the department 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 (co-pays) (unless the criteria in chapter 388-517 WAC or WAC 388-501-0200 are met);

     (b) Deductibles (unless the criteria in chapter 388-517 WAC or WAC 388-501-0200 are met);

     (c) Emergency Medical Expense Requirements (EMER); and

     (d) Spenddown (see WAC 388-519-0110).

     (4) The provider must accept medicare assignment for claims involving clients eligible for both medicare and medical assistance before MAA makes any payment.

     (5) The provider is responsible for verifying whether a client has medical assistance coverage for the dates of service.

     (6) The department may reimburse a provider for services provided to a person if it is later determined that the person was ineligible for the service at the time it was provided if:

     (a) The department 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 department.

     (7) The department 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 department.

     (8) Information about medical care for jail inmates is found in RCW 70.48.130.

     (9) The department pays for medically necessary services on the basis of usual and customary charges or the maximum allowable fee established by the department, whichever is lower.



[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.]