Section 182-543-9250. Reimbursement method—Complex rehabilitation technology.

(1) The agency reimburses a complex rehabilitation technology (CRT) provider for purchased CRT products based on the assigned health care common procedure coding system (HCPCS) code. The agency requires providers to make sure the specific brand and model of CRT products dispensed are coded according to the Centers for Medicare and Medicaid Services' (CMS) pricing, data analysis, and coding (PDAC) web site.

(2) The agency sets, evaluates, and updates the maximum allowable fees at least once yearly for CRT products using the lesser of the following:

(a) The current medicare fees;

(b) A pricing cluster; or

(c) On a by-report basis.

(3) To establish a rate based on a pricing cluster, the agency uses the following methodology:

(a) The pricing cluster is based on a specific HCPCS code;

(b) The pricing cluster includes all brands/models for which the agency obtains pricing information;

(c) The agency may limit the number of brands/models included in the pricing cluster based on the following:

(i) Product quality;

(ii) Introduction, substitution or discontinuation of certain brands/models; and

(iii) Cost, when there are equally effective substantially less costly alternatives available.

(d) When establishing the fee for CRT products in a pricing cluster, the maximum allowable fee is the median cost of all manufacturers' list prices for all brands/models in the cluster.

(4) The agency evaluates by-report (BR) items, procedure, or service for medical necessity, appropriateness and reimbursement value on a case-by-case basis. The agency calculates the reimbursement rate for these items at a percentage of the manufacturer's suggested retail price (MSRP) as of January 31st of the base year, or a percentage of the wholesale acquisition cost (AC) from the manufacturer's invoice. The agency uses the following percentages:

(a) For add-on CRT accessories and parts, eighty-four percent of MSRP or one hundred forty percent of AC;

(b) For up-charge modifications, seating systems, back and seat cushions, eighty percent of MSRP or one hundred forty percent of AC;

(c) For CRT manual wheelchair base, eighty percent of MSRP or one hundred forty percent of AC; and

(d) For CRT power-drive wheelchair base, eighty-five percent of MSRP or one hundred forty percent of AC.

(5) The agency may adopt policies, procedure codes, and/or rates that are inconsistent with those set by medicare if the agency determines that such actions are necessary to:

(a) Assure that payments are sufficient to enlist providers and maintain access to care and services; or

(b) Comply with legislative budget directives specifically reducing available funds for optional programs as an alternative to eliminating the optional program.

[Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-9250, filed 3/25/14, effective 4/25/14.]

RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-9250, filed 3/25/14, effective 4/25/14.