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PDFWAC 388-97-0100

Utilization review.

(1) To assure appropriate use of medicaid services, the nursing facility must determine whether each medicaid resident's health has improved sufficiently so the resident no longer needs nursing facility care.
(a) The nursing facility must base its determination on:
(i) An accurate, comprehensive assessment process; and
(ii) Documentation by the resident's physician.
(b) The nursing facility is not responsible to assess under WAC 388-97-1960, PASSR level II screening assessment.
(2) When the nursing facility determines a resident no longer needs nursing facility care under subsection (1) of this section, the nursing facility must initiate transfer or discharge in accordance with WAC 388-97-0120, 388-97-0140, and 42 C.F.R. § 483.12, or successor laws, unless the resident voluntarily chooses to transfer or discharge.
(3) When a nursing facility initiates a transfer or discharge of a medicaid recipient under subsection (2) of this section:
(a) The resident will be ineligible for medicaid nursing facility payment:
(i) Thirty days after the receipt of written notice of transfer or discharge; or
(ii) If the resident appeals the facility determination, thirty days after the final order is entered upholding the nursing home's decision to transfer or discharge a resident.
(b) The department's home and community services may grant extension of a resident's medicaid nursing facility payment after the time specified in subsection (3)(a) of this section, when the department's home and community services staff determine:
(i) The nursing facility is making a good faith effort to relocate the resident; and
(ii) A location appropriate to the resident's medical and other needs is not available.
(4) Department designees may review any assessment or determination made by a nursing facility of a resident's need for nursing facility care.
[Statutory Authority: Chapters 18.51 and 74.42 RCW. WSR 10-02-021, § 388-97-0100, filed 12/29/09, effective 1/29/10. Statutory Authority: Chapters 18.51 and 74.42 RCW and 42 C.F.R. 489.52. WSR 08-20-062, § 388-97-0100, filed 9/24/08, effective 11/1/08.]
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