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Washington Administrative Code (Last Updated: November 23, 2016) |
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Title 182. Health Care Authority |
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Chapter 182-538. Managed care. |
Section 182-538-096. Scope of service for PCCM enrollees.
Latest version.
- (1) A primary care case management (PCCM) enrollee is eligible for the scope of services in WAC 182-501-0060 and 182-501-0065. An enrollee is entitled to timely access to covered services that are medically necessary.(a) The agency covers services through the fee-for-service system for enrollees with a primary care case management (PCCM) provider. Except for emergencies, the PCCM provider must either provide the covered services or refer the enrollee to other providers who are contracted with the agency for covered services. The PCCM provider is responsible for explaining to the enrollee how to obtain the services for which the PCCM provider is referring the enrollee. Services that require PCCM provider referral are described in the PCCM contract.(b) The agency sends each enrollee written information about covered services when the client enrolls in managed care and when there is a change in covered services. This information describes covered services, which services are covered by the agency, and how to access services through the PCCM provider.(2) For services covered by the agency through PCCM contracts for managed care:(a) The agency covers medically necessary services included in the categorically needy scope of care and furnished by providers who have a current core provider agreement with the agency to provide the requested service;(b) The agency may require the PCCM provider to obtain authorization from the agency for coverage of nonemergency services;(c) The PCCM provider determines which services are medically necessary;(d) Services referred by the PCCM provider require an authorization number to receive payment from the agency; and(e) An enrollee may request a hearing for review of PCCM provider or agency coverage decisions (see WAC 182-538-110).(3) The following services are not covered:(a) Services that are not medically necessary as defined in WAC 182-500-0070.(b) Services not included in the categorically needy scope of services.(c) Services, other than a screening exam as described in WAC 182-538-100(3), received in a hospital emergency department for nonemergency medical conditions.(d) Services that require a referral from the PCCM provider as described in the PCCM contract, but were not referred by the PCCM provider.
Rules
182-501-0060,182-501-0065,182-538-110,182-500-0070,182-538-100,