Section 182-540-150. Reimbursement—General.

(1) Kidney center services described in this section are paid by one of two methods:

(a) Composite rate payments - This is a payment method in which all standard equipment, supplies, and services are calculated into a blended rate.

(i) A single dialysis session and related services are reimbursed through a single composite rate payment (refer to WAC 182-540-160).

(ii) Composite rate payments for continuous ambulatory peritoneal dialysis (CAPD) or continuous cycling peritoneal dialysis (CCPD) are limited to thirty-one per month for an individual client.

(iii) Composite rate payments for all other types of dialysis sessions are limited to fourteen per month for an individual client.

(b) Noncomposite rate payments - End-stage renal disease (ESRD) services and items covered by the medicaid agency but not included in the composite rate are billed and paid separately (refer to WAC 182-540-170).

(2) Limitation extension request - The agency evaluates billings for covered services that are subject to limitations or other restrictions, and approves the services beyond those limitations or restrictions when medically necessary under WAC 182-501-0165 and 182-501-0169.

(3) Take-home drugs - The agency reimburses kidney centers for take-home drugs only when they meet the conditions described in WAC 182-540-170(1). Other drugs for at-home use must be billed by a pharmacy and be subject to the agency's pharmacy rules.

(4) Medical nutrition - Medical nutrition products must be billed by a pharmacy or a durable medical equipment (DME) provider.

(5) Medicare eligible clients - The agency does not reimburse kidney centers as a primary payer for medicare eligible clients.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-14-040, § 182-540-150, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-540-150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-540-150, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-150, filed 10/8/03, effective 11/8/03.]

RCW 41.05.021 and 41.05.160. WSR 15-14-040, § 182-540-150, filed 6/24/15, effective 7/25/15. WSR 11-14-075, recodified as § 182-540-150, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-540-150, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520, 74.09.522, and 42 C.F.R. 405.2101. WSR 03-21-039, § 388-540-150, filed 10/8/03, effective 11/8/03.

Rules

182-540-160,182-540-170,182-501-0165,182-501-0169,182-540-170,