PDFWAC 296-23A-0230
How does the department or self-insurer pay out-of-state hospitals for hospital services?
The department or self-insurer pays out-of-state hospitals for hospital services using a percent of allowed charges (POAC) factor or department fee schedule. The POAC factor may differ for services performed in inpatient and outpatient settings. Payment rates to hospitals located outside of Washington state are calculated by multiplying the out-of-state percent of allowed charges factor (POAC) by the allowed charges.
Amount paid = (out-of-state POAC Factor) X (Allowed Charges).
Out-of-state hospital providers should bill and the department or self-insurer will pay out-of-state hospitals services according to the following table:
Hospital Professional and Ambulance Services | Hospital Outpatient Services | Hospital Inpatient Services |
Professional and ambulance services should be billed with CPT and HCPCS codes on current Health Insurance Claim Forms (as defined by the National Uniform Claim Committee) under separate provider numbers. These services will be paid using the fee schedule rates and payment policies stated in the Washington Medical Aid Rules and Fee Schedules. | All hospital outpatient services should be billed on UB forms under the hospital provider number with revenue codes. These services will be paid at the out-of-state percent of allowed charges (POAC) factor as stated in the Washington Medical Aid Rules and Fee Schedules. | All hospital inpatient services should be billed on UB forms under the hospital provider number using revenue codes. These services will be paid at the out-of-state percent of allowed charges (POAC) factor as stated in the Washington Medical Aid Rules and Fee Schedules. |
Military and veteran's administration professional and ambulance services should be billed on current Health Insurance Claim Forms (as defined by the National Uniform Claim Committee) and will be paid at 100% of allowed charges. | Military, veteran's administration, health maintenance organization, children's, and state-run psychiatric hospitals will be paid at 100% of allowed charges for outpatient hospital services. | Military, veteran's administration, health maintenance organization, children's, and state-run psychiatric hospitals will be paid at 100% of allowed charges for inpatient hospital services. |
[Statutory Authority: RCW 51.04.020, 51.36.080, 7.68.030, 7.68.080. WSR 07-08-088, § 296-23A-0230, filed 4/3/07, effective 5/23/07. Statutory Authority: RCW 51.04.020, 51.04.030, 51.36.080. WSR 00-09-078, § 296-23A-0230, filed 4/18/00, effective 7/1/00; WSR 97-06-066, § 296-23A-0230, filed 2/28/97, effective 4/1/97.]