Section 182-543-9300. Reimbursement method—Prosthetics and orthotics.

(1) The agency sets, evaluates and updates the maximum allowable fees for prosthetics and orthotics at least once yearly as follows:

(a) For items with a rate on the current medicare fee schedule, as established by the federal Centers for Medicare and Medicaid Services (CMS), the agency equates its maximum allowable fee to the current medicare rate; and

(b) For those items not included in the medicare fee schedule, as established by CMS, the rate is considered by report. The agency evaluates a by report item, procedure, or service based upon medical necessity criteria, appropriateness, and reimbursement value on a case-by-case basis. The agency calculates the reimbursement for these items at eighty-five percent of the manufacturer's list or manufacturer's suggested retail price (MSRP) as of July 31st of the base year or one hundred twenty-five percent of the wholesale acquisition cost from the manufacturer's invoice.

(2) The agency follows health care common procedure coding system (HCPCS) guidelines for product classification and code assignation.

(3) The agency's reimbursement for a prosthetic or orthotic includes the cost of any necessary molds, fitting, shipping, handling or any other administrative expenses related to provision of the prosthetic or orthotic to the client.

(4) The agency's hospital reimbursement rate includes any prosthetics and/or orthotics required for surgery and/or placed during the hospital stay.

(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.

[Statutory Authority: RCW 41.05.021. WSR 12-16-059, § 182-543-9300, filed 7/30/12, effective 8/30/12; WSR 12-07-022, § 182-543-9300, filed 3/12/12, effective 4/12/12. WSR 11-14-075, recodified as § 182-543-9300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-9300, filed 6/29/11, effective 8/1/11.]

RCW 41.05.021. WSR 12-16-059, § 182-543-9300, filed 7/30/12, effective 8/30/12; WSR 12-07-022, § 182-543-9300, filed 3/12/12, effective 4/12/12. WSR 11-14-075, recodified as § 182-543-9300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-9300, filed 6/29/11, effective 8/1/11.