PDFWAC 182-554-100
Enteral nutrition—General.
(1) The agency covers the enteral nutrition products, equipment, and related supplies listed in this chapter, according to medicaid agency rules and subject to the limitations and requirements in this chapter.
(2) The agency pays for covered enteral nutrition products, equipment and related supplies if they are:
(a) Within the scope of the eligible client's medical care program;
(b) Medically necessary under WAC 182-500-0070; and
(c) Authorized and billed, as required within this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions.
(3) The agency requires prior authorization (PA) for covered enteral nutrition products, equipment and related supplies when the clinical criteria described in this chapter are not met, including the criteria associated with the expedited prior authorization process. The agency evaluates requests requiring PA on a case-by-case basis to determine whether they are medically necessary under WAC 182-501-0165.
(4) The agency evaluates a request for a covered service that is experimental or investigational under WAC 182-531-0550 and 182-501-0165.
(5) The agency may terminate a provider's core provider agreement under chapter 182-502 WAC.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-08-009, § 182-554-100, filed 3/24/17, effective 5/1/17. WSR 11-14-075, recodified as § 182-554-100, 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, § 388-554-100, 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, § 388-554-100, filed 1/28/05, effective 3/1/05.]