Section 182-554-700. Enteral nutrition products, equipment and related supplies—Authorization.

(1) The department requires providers to obtain authorization for covered orally administered enteral nutrition products, and tube-delivered enteral equipment and related supplies as required in this chapter and in published department billing instructions and/or numbered memoranda or when the clinical criteria required in this chapter are not met.

(a) For prior authorization (PA), a provider must submit a written request to the department as specified in WAC 388-554-500(2).

(b) For expedited prior authorization (EPA), a provider must establish that the client's condition meets the clinically appropriate EPA criteria outlined in this chapter and in the department's published enteral nutrition billing instructions. The appropriate EPA number must be used when the provider bills the department.

(c) Upon request, a provider must provide documentation to the department showing how the client's condition met the criteria for PA or EPA.

(2) Authorization requirements in this chapter are not a denial of service for the client.

(3) When an oral enteral nutrition product or tube-delivered enteral nutrition equipment or related supply requires authorization, the provider must properly request authorization in accordance with the department's rules, billing instructions, and numbered memoranda.

(4) When authorization is not properly requested, the department rejects and returns the request to the provider for further action. The department does not consider the rejection of the request to be a denial of service.

(5) The department's authorization does not necessarily guarantee payment.

(6) The department evaluates requests for authorization for covered enteral nutrition products, equipment, and related supplies that exceed limitations in this chapter on a case-by-case basis in accordance with WAC 388-501-0169.

(7) The department may recoup any payment made to a provider if the department later determines that the service was not properly authorized or did not meet the EPA criteria. Refer to WAC 388-502-0100 (1)(c).

(8) If a fee-for-service client enrolls in a department-contracted MCO before the department completes the purchase or rental of prescribed enteral nutrition products, necessary equipment and supplies:

(a) The department rescinds the authorization of the purchase or rental;

(b) The department stops paying for any equipment on the last day of the month preceding the month in which the client becomes enrolled in the managed care plan; and

(c) The department-contracted MCO determines the client's continuing need for the equipment and is then responsible for the client.

(9) The department rescinds any authorization for prescribed equipment if the equipment was not delivered to the client before the client:

(a) Loses medical eligibility;

(b) Becomes covered by a hospice agency and the equipment is used in the treatment of the terminal diagnosis or related condition(s);

(c) Becomes eligible for a department-contracted managed care plan; or

(d) Dies.

[WSR 11-14-075, recodified as § 182-554-700, filed 6/30/11, effective 7/1/11. Statutory Authority: 2009 c 564 § 1109, RCW 74.04.050, and 74.08.090. WSR 10-01-138, § 388-554-700, filed 12/21/09, effective 1/21/10. Statutory Authority: RCW 74.08.090, 74.09.530 and chapter 74.09 RCW. WSR 05-04-059, § 388-554-700, filed 1/28/05, effective 3/1/05.]

WSR 11-14-075, recodified as § 182-554-700, filed 6/30/11, effective 7/1/11. Statutory Authority: 2009 c 564 § 1109, RCW 74.04.050, and 74.08.090. WSR 10-01-138, § 388-554-700, filed 12/21/09, effective 1/21/10. Statutory Authority: RCW 74.08.090, 74.09.530 and chapter 74.09 RCW. WSR 05-04-059, § 388-554-700, filed 1/28/05, effective 3/1/05.

Rules

388-554-500,388-501-0169,388-502-0100,