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PDFWAC 296-31-080

How do providers bill for services?

(1) Neither the department nor the claimant is required to pay for provider services which violate the mental health treatment rules, fee schedule or department policy.
(2) All fees listed are the maximum fees allowable. Providers must bill their usual and customary fee for each service. If this is less than our fee schedule rate, you must bill us at the lesser rate. The department will pay the lesser of the billed charge or the fee schedule’s maximum allowable.
The provider is prohibited from charging the claimant for any difference between the provider's charge and our allowable amount.
(3) Regardless of who completes the bill form, you are responsible for the completeness and accuracy of the description of services and of the charges billed.
(4) All bills submitted to the department must:
(a) Be itemized on forms approved by us.
For example: Physicians, psychologists, advanced registered nurse practitioners and master level mental health counselors may use our form or the current Health Insurance Claim Form (as defined by the National Uniform Claim Committee). Hospitals use the current National Uniform Billing Form (as defined by the National Uniform Billing Committee) for institution services and the current Health Insurance Claim Form (as defined by the National Uniform Claim Committee) for professional services.
(b) Refer to the crime victims compensation program mental health billing instructions for detailed billing information. Billings must be submitted in accordance with these instructions. Procedure codes and fees are available on the crime victims compensation website or by contacting the crime victims program.
(5) The following supporting documentation must be maintained and, if applicable, submitted when billing for services:
(a) Intake evaluation;
(b) Progress reports;
(c) Consultation reports;
(d) Special or diagnostic study reports;
(e) Independent assessment or closing exam reports;
(f) BR (by report) describing why a service or procedure is too unusual, variable, or complex to be assigned a value unit;
(g) The claimant’s or patient’s (if patient is other than claimant) private or public insurance information;
For example: When services provided are for survivors of homicide victims.
(6) The claim number must appear in the appropriate field on each bill form. Reports and other correspondence must have the claim number in the upper right hand corner of each page.
(7) You may rebill us if your bill is not reported on your remittance advice within sixty days. Unless the information on the original bill was incorrect, a rebill should be identical. Rebills must be submitted for services denied if a claim is closed or rejected and subsequently reopened or allowed.
(8) We will adjust charges when appropriate. We must provide you with a written explanation as to why a billing was adjusted. A written explanation is not required if the adjustment was made solely to conform to our maximum allowable fees. Any inquiries regarding adjustment of charges must be received in the required format within ninety days from the date of payment.
[Statutory Authority: RCW 51.04.020, 51.36.080, 7.68.030, 7.68.080. WSR 07-08-088, § 296-31-080, filed 4/3/07, effective 5/23/07. Statutory Authority: RCW 7.68.030, 7.68.080, 7.68.120, 51.36.010, 51.04.020 (1) and (4) and 51.04.030. WSR 99-07-004, § 296-31-080, filed 3/4/99, effective 4/4/99; WSR 97-02-090, § 296-31-080, filed 12/31/96, effective 1/31/97. Statutory Authority: RCW 7.68.030, 51.04.020(1) and 51.04.030. WSR 95-15-004, § 296-31-080, filed 7/5/95, effective 8/5/95. Statutory Authority: Chapter 7.68 RCW. WSR 94-02-015, § 296-31-080, filed 12/23/93, effective 1/24/94. Statutory Authority: RCW 43.22.050. WSR 92-23-033, § 296-31-080, filed 11/13/92, effective 12/14/92.]
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