Chapter 182-537 WAC
Last Update: 3/22/23SCHOOL-BASED HEALTH CARE SERVICES
WAC Sections
| HTMLPDF | 182-537-0100 | Purpose. |
| HTMLPDF | 182-537-0200 | Definitions. |
| HTMLPDF | 182-537-0300 | Student eligibility. |
| HTMLPDF | 182-537-0350 | Provider qualifications. |
| HTMLPDF | 182-537-0400 | Covered services. |
| HTMLPDF | 182-537-0500 | Noncovered services. |
| HTMLPDF | 182-537-0600 | School district requirements for billing and payment. |
| HTMLPDF | 182-537-0700 | School district documentation requirements. |
| HTMLPDF | 182-537-0800 | Program integrity. |
PDF182-537-0100
Purpose.
The medicaid agency pays contracted school districts, educational service districts, charter schools, and tribal schools for school-based health care services provided to medicaid-eligible children who require early intervention or special education and related services consistent with Sections 1903(c) and 1905(a) of the Social Security Act. The agency pays school districts through fee-for-service. Covered services must:
(1) Identify, treat, and manage the disabilities of a child who requires early intervention or special education and related services;
(2) Be prescribed or recommended by licensed physicians or other licensed health care providers within their scope of practice under state law;
(3) Be medically necessary;
(4) Be included in the child's current individualized education program (IEP) or individualized family service plan (IFSP); and
(5) Be provided in a school setting, the natural environment, an alternate placement in accordance with the Individuals with Disabilities Education Act (IDEA), or by telemedicine.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-14-062, § 182-537-0100, filed 6/26/20, effective 7/27/20; WSR 19-04-095, § 182-537-0100, filed 2/5/19, effective 3/8/19; WSR 16-07-141, § 182-537-0100, filed 3/23/16, effective 4/23/16. Statutory Authority: RCW 41.05.021. WSR 13-05-017, § 182-537-0100, filed 2/7/13, effective 3/10/13. WSR 11-14-075, recodified as § 182-537-0100, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0100, filed 3/4/09, effective 4/4/09. Statutory Authority: RCW 74.08.090. WSR 01-02-076, § 388-537-0100, filed 12/29/00, effective 1/29/01. Statutory Authority: RCW 74.04.050 and 74.08.090. WSR 00-01-088, § 388-537-0100, filed 12/14/99, effective 1/14/00.]
PDF182-537-0200
Definitions.
The following definitions and those found in chapter 182-500 WAC apply to this chapter:
"Agency" - See WAC 182-500-0010.
"Assessment" - For the purposes of this chapter, an assessment is made-up of medically necessary tests given to an individual child by a licensed health care provider to evaluate whether a child with a disability is in need of early intervention services or special education and related services. Assessments are a part of the individualized education program (IEP) and individualized family service plan (IFSP) evaluation and reevaluation processes.
"Charter school" - A public school governed by a charter school board and operated according to the terms of the charter school contract. Charter schools are open to all students, do not charge tuition, and do not have special entrance requirements.
"Child with a disability" - For purposes of this chapter, a child with a disability is a child evaluated and determined to need early intervention services or special education and related services because of a disability in one or more of the following eligibility categories:
• Autism;
• Deaf-blindness;
• Developmental delay for children ages three through nine, with an adverse educational impact, the results of which require special education and related direct services;
• Hearing loss (including deafness);
• Intellectual disability;
• Multiple disabilities;
• Orthopedic impairment;
• Other health impairment;
• Serious emotional disturbance (emotional behavioral disturbance);
• Specific learning disability;
• Speech or language impairment;
• Traumatic brain injury; and
• Visual impairment (including blindness).
"Core provider agreement" – See WAC 182-500-0020.
"Early intervention services" - Means developmental services provided to children ages birth through two. For the purposes of this chapter, early intervention services include:
• Audiology services;
• Health services;
• Nursing services;
• Occupational therapy;
• Physical therapy;
• Psychological services; and
• Speech-language pathology.
"Educational service district" - A regional agency which provides cooperative and informal services to local school districts within defined regions of the state.
"Electronic signature" - See WAC 182-500-0030.
"Evaluation" - Procedures used to determine whether a child has a disability, and the nature and extent of the early intervention or special education and related services needed. (See WAC 392-172A-01070 and 34 C.F.R. Sec. 303.321.)
"Fee-for-service" - See WAC 182-500-0035.
"Handwritten signature" - A scripted name or legal mark of an individual on a document to signify knowledge, approval, acceptance, or responsibility of the document.
"Health care-related services" - For the purposes of this chapter, means developmental, corrective, and other supportive services required to assist a student ages three through twenty eligible for special education and include:
• Audiology;
• Counseling;
• School health services and school nurse services;
• Occupational therapy;
• Physical therapy;
• Psychological assessments and services; and
• Speech-language therapy.
"Individualized education program (IEP)" - A written educational program for a child who is age three through twenty-one and eligible for special education. An IEP is developed, reviewed and revised according to WAC 392-172A-03090 through 392-172A-03115.
"Individualized family service plan (IFSP)" - A plan for providing early intervention services to a child birth through age two, with a disability or developmental delay and the child's family. The IFSP:
• Is based on the evaluation and assessment described in 34 C.F.R. Sec. 303.321;
• Includes the content specified in 34 C.F.R. Sec. 303.344; and
• Is developed under the IFSP procedures in 34 C.F.R. Secs. 303.342, 303.343, and 303.345.
"Medically necessary" - See WAC 182-500-0070.
"National provider identifier (NPI)" - See WAC 182-500-0075.
"Reevaluation" - Procedures used to determine whether a child continues to need early intervention services or special education and related services. (See WAC 392-172A-03015 and 34 C.F.R. Secs. 303.342 and 303.343.)
"Related services" – See WAC 392-172A-01155.
"School-based health care services contract" - A contract that describes and defines the relationship between the agency, the school-based health care services program, and the school district, ESD, charter, or tribal school.
"School-based health care services program" or "SBHS" - Is an agency-administered program that pays contracted school districts, educational service districts (ESDs), charter schools, and tribal schools for providing early intervention services or special education health-related services to children ages birth through twenty who have an IEP or IFSP.
"School district" - A group of schools administered by a particular authority within defined geographical division.
"Signature log" - A typed list that verifies a licensed provider's identity by associating each provider's signature with their name, handwritten initials, credentials, license and national provider identifier (NPI).
"Special education" - See WAC 392-172A-01175.
"Supervision" - Means supervision provided by a licensed health care provider either directly or indirectly to assist the supervisee in the administration of early intervention or health care-related services outlined in the IEP or IFSP.
"Telemedicine" - See WAC 182-501-0300.
[Statutory Authority: RCW 41.05.021, 41.05.160, and 2021 c 157. WSR 23-04-048, § 182-537-0200, filed 1/26/23, effective 2/26/23. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-14-062, § 182-537-0200, filed 6/26/20, effective 7/27/20; WSR 19-04-095, § 182-537-0200, filed 2/5/19, effective 3/8/19; WSR 16-07-141, § 182-537-0200, filed 3/23/16, effective 4/23/16. Statutory Authority: RCW 41.05.021, 34 C.F.R. 300.154(d), and chapter 182-502 WAC. WSR 13-21-079, § 182-537-0200, filed 10/17/13, effective 11/17/13. Statutory Authority: RCW 41.05.021. WSR 13-05-017, § 182-537-0200, filed 2/7/13, effective 3/10/13. WSR 11-14-075, recodified as § 182-537-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0200, filed 3/4/09, effective 4/4/09.]
PDF182-537-0300
Student eligibility.
(1) Contracted school districts may receive medicaid payment for students ages birth through twenty who:
(a) Have an active individualized family service plan (IFSP) or individualized education program (IEP); and
(b) Who are receiving Title XIX medicaid under a Washington apple health categorically needy program (CNP) or medically needy program (MNP).
(2) Eligible students enrolled in an agency-contracted managed care organization (MCO) are eligible to receive school-based health care services through fee-for-service.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-04-095, § 182-537-0300, filed 2/5/19, effective 3/8/19; WSR 16-07-141, § 182-537-0300, filed 3/23/16, effective 4/23/16. Statutory Authority: RCW 41.05.021 and Patient Protection and Affordable Care Act (Public Law 111-148). WSR 14-07-042, § 182-537-0300, filed 3/12/14, effective 4/12/14. WSR 11-14-075, recodified as § 182-537-0300, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0300, filed 3/4/09, effective 4/4/09.]
PDF182-537-0350
Provider qualifications.
(1) School-based health care services (SBHS) must be delivered by or under the supervision of health care providers who are enrolled with the medicaid agency and who meet state licensure requirements, including active, unrestricted department of health (DOH) licensure. The following people may provide SBHS:
(a) Licensed audiologists;
(b) Licensed social workers;
(c) Licensed mental health counselors (LMHC);
(d) Licensed mental health counselor associates (LMHCA) practicing under the supervision of a licensed mental health provider;
(e) Advanced registered nurse practitioners (ARNP);
(f) Registered nurses (RN);
(g) Licensed practical nurses (LPN) practicing under the supervision of an ARNP or licensed RN;
(h) Licensed occupational therapists (OT);
(i) Licensed occupational therapist assistants (OTA) practicing under the supervision of a licensed OT;
(j) Licensed physical therapists (PT);
(k) Licensed physical therapist assistants (PTA) practicing under the supervision of a licensed PT;
(l) Licensed psychologists;
(m) Licensed speech-language pathologists (SLP);
(n) Speech-language pathology assistants (SLPA) practicing under the supervision of a licensed SLP;
(o) Audiologist and speech language pathologist interim permit holders practicing under the supervision of a licensed audiologist or SLP; and
(p) Nonlicensed people providing services under the supervision of a licensed provider.
(2) For services provided under the supervision of a licensed provider, the provider must:
(a) Ensure the child receives quality services by providing supervision in accordance with professional practice standards; and
(b) Review and cosign all treatment notes written by the supervisee before submitting claims for payment.
(3) The school district must ensure providers meet the professional licensing requirements described in the agency's SBHS billing guide and in this chapter.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-14-062, § 182-537-0350, filed 6/26/20, effective 7/27/20; WSR 19-04-095, § 182-537-0350, filed 2/5/19, effective 3/8/19; WSR 16-07-141, § 182-537-0350, filed 3/23/16, effective 4/23/16. Statutory Authority: RCW 41.05.021, 34 C.F.R. 300.154(d), and chapter 182-502 WAC. WSR 13-21-079, § 182-537-0350, filed 10/17/13, effective 11/17/13. Statutory Authority: RCW 41.05.021. WSR 13-05-017, § 182-537-0350, filed 2/7/13, effective 3/10/13. WSR 11-14-075, recodified as § 182-537-0350, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0350, filed 3/4/09, effective 4/4/09.]
PDF182-537-0400
Covered services.
Covered school-based health care (SBHS) services include:
(1) Evaluations when the child is determined to have a disability, and is in need of early intervention services or special education and health care-related services that result in an individualized education program (IEP) or individualized family service plan (IFSP);
(2) Health care-related services authorized in an IEP or IFSP limited to:
(a) Audiology;
(b) School health services and school nursing services;
(c) Occupational therapy;
(d) Physical therapy;
(e) Mental health services; and
(f) Speech-language therapy.
(3) Reevaluations, to determine whether a child continues to need early intervention services or special education and health care-related services.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 20-14-062, § 182-537-0400, filed 6/26/20, effective 7/27/20; WSR 19-04-095, § 182-537-0400, filed 2/5/19, effective 3/8/19; WSR 16-07-141, § 182-537-0400, filed 3/23/16, effective 4/23/16. Statutory Authority: RCW 41.05.021. WSR 13-05-017, § 182-537-0400, filed 2/7/13, effective 3/10/13. WSR 11-14-075, recodified as § 182-537-0400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0400, filed 3/4/09, effective 4/4/09.]
PDF182-537-0500
Noncovered services.
Noncovered services include, but are not limited to the following:
(1) Applied behavior analysis (ABA);
(2) Attending meetings;
(3) Charting;
(4) Instructional assistant contact;
(5) Observation not provided directly after service delivery;
(6) Parent consultation;
(7) Parent contact;
(8) Planning;
(9) Preparing and sending correspondence to parents or other professionals;
(10) Professional consultation;
(11) Report writing;
(12) Review of records;
(13) School district staff accompanying a child who requires special education services to and from school on the bus when direct services are not provided;
(14) Supervision;
(15) Teacher contact;
(16) Test interpretation; and
(17) Travel and transporting.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-04-095, § 182-537-0500, filed 2/5/19, effective 3/8/19; WSR 16-07-141, § 182-537-0500, filed 3/23/16, effective 4/23/16. Statutory Authority: RCW 41.05.021. WSR 13-05-017, § 182-537-0500, filed 2/7/13, effective 3/10/13. WSR 11-14-075, recodified as § 182-537-0500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0500, filed 3/4/09, effective 4/4/09.]
PDF182-537-0600
School district requirements for billing and payment.
To receive payment from the medicaid agency for providing school-based health care services (SBHS) to eligible children, a school district must:
(1) Enroll as a billing provider in ProviderOne and have a current, signed core provider agreement (CPA) with the agency.
(2) Have a current, signed, and executed SBHS contract with the agency.
(3) Meet the applicable requirements in chapter 182-502 WAC.
(4) Comply with the applicable requirements in the agency's current, published ProviderOne billing and resource guide.
(5) Bill according to the agency's current SBHS billing guide and the SBHS fee schedule.
(6) Provide only early intervention or health care-related services identified through a current individualized education program (IEP) or individualized family service plan (IFSP).
(7) Use only licensed health care providers or nonlicensed people practicing under the supervision of a licensed provider under WAC 182-537-0350.
(8) Enroll licensed health care providers as servicing providers under the school district's ProviderOne account, and ensure providers have their own national provider identifier (NPI) number.
(9) Meet documentation requirements described in WAC 182-537-0700.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 22-14-019, § 182-537-0600, filed 6/24/22, effective 8/1/22; WSR 20-14-062, § 182-537-0600, filed 6/26/20, effective 7/27/20; WSR 19-04-095, § 182-537-0600, filed 2/5/19, effective 3/8/19; WSR 16-07-141, § 182-537-0600, filed 3/23/16, effective 4/23/16. Statutory Authority: RCW 41.05.021, 34 C.F.R. 300.154(d), and chapter 182-502 WAC. WSR 13-21-079, § 182-537-0600, filed 10/17/13, effective 11/17/13. Statutory Authority: RCW 41.05.021. WSR 13-05-017, § 182-537-0600, filed 2/7/13, effective 3/10/13. WSR 11-14-075, recodified as § 182-537-0600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0600, filed 3/4/09, effective 4/4/09.]
PDF182-537-0700
School district documentation requirements.
(1) Providers must document all school-based health care services as required in this section and the medicaid agency's school-based health care services (SBHS) billing guide.
(2) Documentation to justify billed claims must be maintained for at least six years from the date of service.
(3) Records for each student must include, but are not limited to:
(a) A referral or prescription for services by a physician or other licensed health care provider within their scope of practice;
(b) Assessment reports;
(c) Evaluation and reevaluation reports;
(d) Individualized education program (IEP) or individualized family service plan (IFSP);
(e) Attendance records; and
(f) Treatment notes. Treatment notes must include the:
(i) Child's name;
(ii) Child's ProviderOne client ID;
(iii) Child's date of birth;
(iv) Date of service, and for each date of service:
(A) Time-in;
(B) Time-out;
(C) A procedure code for and description of each service provided;
(D) The child's progress related to each service;
(E) Whether the occupational therapy, speech-language therapy, physical therapy or counseling service described in the note was individual or group therapy;
(F) The licensed provider's printed name, handwritten or electronic signature, and title; and
(G) Assistants and nonlicensed people, as defined in WAC 182-537-0350, who provide early intervention or health care-related services under supervision, must have a licensed provider review and cosign all treatment notes.
(4) The agency accepts electronic records and electronic signatures under chapter 1.80 RCW. Each school district is responsible for determining what standards are consistent with state and federal electronic record and electronic signature requirements.
(5) For a signature to be valid, it must be handwritten or electronic. Signature by stamp is acceptable only if the provider is unable to sign by hand due to a physical disability.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 23-07-133, § 182-537-0700, filed 3/22/23, effective 7/1/23; WSR 20-14-062, § 182-537-0700, filed 6/26/20, effective 7/27/20; WSR 19-04-095, § 182-537-0700, filed 2/5/19, effective 3/8/19; WSR 16-07-141, § 182-537-0700, filed 3/23/16, effective 4/23/16; WSR 14-20-090, § 182-537-0700, filed 9/29/14, effective 10/30/14. Statutory Authority: RCW 41.05.021. WSR 13-05-017, § 182-537-0700, filed 2/7/13, effective 3/10/13. WSR 11-14-075, recodified as § 182-537-0700, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0700, filed 3/4/09, effective 4/4/09.]
PDF182-537-0800
Program integrity.
(1) To ensure compliance with program rules, the medicaid agency conducts program integrity activities under chapters 182-502 and 182-502A WAC.
(2) School districts must participate in all program integrity activities.
(3) School districts are responsible for the accuracy, compliance, and completeness of all claims submitted for medicaid payment.
(4) The agency conducts reviews and recovers overpayments if a school district does not comply with agency requirements according to agency rules.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 19-04-095, § 182-537-0800, filed 2/5/19, effective 3/8/19; WSR 16-07-141, § 182-537-0800, filed 3/23/16, effective 4/23/16. Statutory Authority: RCW 41.05.021. WSR 13-05-017, § 182-537-0800, filed 2/7/13, effective 3/10/13. WSR 11-14-075, recodified as § 182-537-0800, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.500, and 42 C.F.R. 440.110. WSR 09-07-004, § 388-537-0800, filed 3/4/09, effective 4/4/09.]