WAC 388-531-0100   Scope of coverage for physician-related services -- General and administrative.  (1) The department covers healthcare services, equipment, and supplies listed in this chapter, according to department rules and subject to the limitations and requirements in this chapter, when they are:

     (a) Within the scope of an eligible client's medical assistance program. Refer to WAC 388-501-0060 and 388-501-0065; and

     (b) Medically necessary as defined in WAC 388-500-0005.

     (2) The department evaluates a request for a service that is in a covered category under the provisions of WAC 388-501-0165.

     (3) The department evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions as described in WAC 388-501-0169.

     (4) The department covers the following physician-related services, subject to the conditions in subsections (1), (2), and (3) of this section:

     (a) Allergen immunotherapy services;

     (b) Anesthesia services;

     (c) Dialysis and end stage renal disease services (refer to chapter 388-540 WAC);

     (d) Emergency physician services;

     (e) ENT (ear, nose, and throat) related services;

     (f) Early and periodic screening, diagnosis, and treatment (EPSDT) services (refer to WAC 388-534-0100);

     (g) Family planning services (refer to chapter 388-532 WAC);

     (h) Hospital inpatient services (refer to chapter 388-550 WAC);

     (i) Maternity care, delivery, and newborn care services (refer to chapter 388-533 WAC);

     (j) Office visits;

     (k) Vision-related services, refer to chapter 388-544 WAC;

     (l) Osteopathic treatment services;

     (m) Pathology and laboratory services;

     (n) Physiatry and other rehabilitation services (refer to chapter 388-550 WAC);

     (o) Podiatry services;

     (p) Primary care services;

     (q) Psychiatric services, provided by a psychiatrist;

     (r) Psychotherapy services for children as provided in WAC 388-531-1400;

     (s) Pulmonary and respiratory services;

     (t) Radiology services;

     (u) Surgical services;

     (v) Cosmetic, reconstructive, or plastic surgery, and related services and supplies to correct physiological defects from birth, illness, or physical trauma, or for mastectomy reconstruction for post cancer treatment; and

     (w) Other outpatient physician services.

     (5) The department covers physical examinations for medical assistance clients only when the physical examination is one or more of the following:

     (a) A screening exam covered by the EPSDT program (see WAC 388-534-0100);

     (b) An annual exam for clients of the division of developmental disabilities; or

     (c) A screening pap smear, mammogram, or prostate exam.

     (6) By providing covered services to a client eligible for a medical assistance program, a provider who has signed an agreement with the department accepts the department's rules and fees as outlined in the agreement, which includes federal and state law and regulations, billing instructions, and department issuances.



[Statutory Authority: RCW 74.09.521. 08-12-030, § 388-531-0100, filed 5/29/08, effective 7/1/08. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-531-0100, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.520. 01-01-012, § 388-531-0100, filed 12/6/00, effective 1/6/01.]