WAC 388-531-2000
Increased payments for
physician-related services for qualified trauma cases. (1)
The department's trauma care fund (TCF) is an amount that is
legislatively appropriated to DSHS each biennium for the
purpose of increasing the department's payment to eligible
physicians and other clinical providers for providing
qualified trauma services to medicaid, general
assistance-unemployable (GA-U), and Alcohol and Drug Addiction
Treatment and Support Act (ADATSA) fee-for-service clients. Claims for trauma care provided to clients enrolled in the
department's managed care programs are not eligible for
increased payments from the TCF.
(2) Beginning with services provided after June 30, 2003,
the department makes increased payments from the TCF to
physicians and other clinical providers who provide trauma
services to medicaid, GA-U, and ADATSA clients, subject to the
provisions in this section. A provider is eligible to receive
increased payments from the TCF for trauma services provided
to a GA-U or ADATSA client during the client's certification
period only. See WAC 388-416-0010.
(3) The department makes increased payments from the TCF
to physicians and other clinical providers who:
(a) Are on the designated trauma services response team
of any department of health (DOH)-designated trauma service
center;
(b) Meet the provider requirements in this section and
other applicable WAC;
(c) Meet the billing requirements in this section and
other applicable WAC; and
(d) Submit all information the department requires to
ensure trauma services are being provided.
(4) Except as described in subsection (5) of this section
and subject to the limitations listed, the department makes
increased payments from the TCF to physicians and other
eligible clinical providers:
(a) For only those trauma services that are designated by
the department as "qualified." These qualified services must
be provided to eligible fee-for-service medicaid, GA-U, and
ADATSA clients. Qualified trauma services include care
provided within six months of the date of injury for surgical
procedures related to the injury if the surgical procedures
were planned during the initial acute episode of injury.
(b) For hospital-based services only.
(c) Only for trauma cases that meet the injury severity
score (ISS) (a summary rating system for traumatic anatomic
injuries) of:
(i) Thirteen or greater for an adult trauma patient (a
client age fifteen or older); or
(ii) Nine or greater for a pediatric trauma patient (a
client younger than age fifteen).
(d) On a per-client basis in any DOH designated trauma
service center.
(e) At a rate of two and one-half times the current
department fee-for-service rate for qualified trauma services,
or other payment enhancement percentage the department
determines as appropriate.
(i) The department monitors the increased payments from
the TCF during each state fiscal year (SFY) and makes
necessary adjustments to the rate to ensure that total
payments from the TCF for the biennium will not exceed the
legislative appropriation for that biennium.
(ii) Laboratory and pathology charges are not eligible
for increased payments from the TCF. (See subsection (6)(b)
of this section.)
(5) When a trauma case is transferred from one hospital
to another, the department makes increased payments from the
TCF to physicians and other eligible clinical providers,
according to the ISS score as follows:
(a) If the transferred case meets or exceeds the
appropriate ISS threshold described in subsection (4)(c) of
this section, eligible providers who furnish qualified trauma
services in both the transferring and receiving hospitals are
eligible for increased payments from the TCF.
(b) If the transferred case is below the ISS threshold
described in subsection (4)(c) of this section, only the
eligible providers who furnish qualified trauma services in
the receiving hospital are eligible for increased payments
from the TCF.
(6) The department distributes increased payments from
the TCF only:
(a) When eligible trauma claims are submitted with the
appropriate trauma indicator within the time frames specified
by the department; and
(b) On a per-claim basis. Each qualifying trauma service
and/or procedure on the physician's claim or other clinical
provider's claim is paid at the department's current
fee-for-service rate, multiplied by an increased TCF payment
rate that is based on the appropriate rate described in
subsection (4)(e) of this section. Charges for laboratory and
pathology services and/or procedures are not eligible for
increased payments from the TCF and are paid at the
department's current fee-for-service rate.
(7) For purposes of the increased payments from the TCF
to physicians and other eligible clinical providers, all of
the following apply:
(a) The department may consider a request for a claim
adjustment submitted by a provider only if the claim is
received by the department within one year from the date of
the initial trauma service;
(b) The department does not allow any carryover of
liabilities for an increased payment from the TCF beyond three
hundred sixty-five days from the date of service. The
deadline for making adjustments to a trauma claim for an SFY
is the same as the deadline for submitting the initial claim
to the department as specified in WAC 388-502-0150(3). WAC 388-502-0150(7) does not apply to TCF claims;
(c) All claims and claim adjustments are subject to
federal and state audit and review requirements; and
(d) The total amount of increased payments from the TCF
disbursed to providers by the department in a biennium cannot
exceed the amount appropriated by the legislature for that
biennium. The department has the authority to take whatever
actions are needed to ensure the department stays within the
current TCF appropriation (see subsection (4)(e)(i) of this
section).
[Statutory Authority: RCW 74.08.090, 74.09.500, and chapter 43.20A RCW. 08-18-029, § 388-531-2000, filed 8/27/08,
effective 9/27/08. Statutory Authority: RCW 74.08.090,
74.09.500. 05-20-050, § 388-531-2000, filed 9/30/05,
effective 10/31/05; 04-19-113, § 388-531-2000, filed 9/21/04,
effective 10/22/04.]