Inpatient psychiatric services.
(1) The medicaid agency or the agency's designee pays for covered inpatient psychiatric services for eligible Washington apple health clients.
(3) To be paid for an inpatient psychiatric admission, the hospital provider or hospital unit provider must meet the requirements for payment including the applicable general conditions of payment criteria in WAC
182-502-0100.
(4) When billing the agency directly for Washington apple health clients not enrolled in an agency-contracted managed care organization (MCO) plan, hospitals may use the expedited prior authorization (EPA) process for inpatient psychiatric services that require authorization when the EPA criteria is met.
(a) To meet the EPA criteria, the inpatient admission must:
(i) Be medically necessary;
(ii) Have psychiatric needs as the focus of treatment and not have an acute medical condition;
(iii) Not have a less-restrictive placement available; and
(iv) Be approved or ordered by the professional in charge of the facility.
(b) If the EPA criteria is not met, a hospital may request prior authorization from the agency or the agency's designee.
(5) Authorization of elective, nonemergency, or emergency-related poststabilization services by an agency-contracted MCO plan are subject to federal rules, including 42 C.F.R. 438.114 and 438.210.
(6) When clients enrolled in an agency-contracted MCO plan are involuntarily detained or committed under chapter
71.05 or
71.34 RCW, the stay must be treated as either an emergency or poststabilization service, and authorization must follow the rules found in 42 C.F.R. 438.114.
(7) When a hospital or hospital unit bills the agency directly, the agency pays the administrative day rate and pays for pharmacy services, pharmaceuticals, and medically necessary ancillary services, as determined by the agency, for any authorized days that meet the administrative day definition in WAC
182-550-1050 when less restrictive alternative treatments are not available, posing a barrier to the client's safe discharge.
(8) The agency may review paid claims and recoup any improperly paid claims, including determining whether the client did not meet EPA criteria or other conditions of payment. See WAC
182-502-0230 and chapter
182-502A WAC.
[Statutory Authority: RCW
41.05.021 and
41.05.160. WSR 24-09-027, § 182-550-2600, filed 4/10/24, effective 5/11/24; WSR 19-18-026, § 182-550-2600, filed 8/28/19, effective 9/28/19; WSR 15-18-065, § 182-550-2600, filed 8/27/15, effective 9/27/15. WSR 11-14-075, recodified as § 182-550-2600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW
74.08.090,
74.09.500. WSR 07-14-053, § 388-550-2600, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW
74.08.090,
74.09.730,
74.04.050,
70.01.010,
74.09.200, [74.09.]500, [74.09.]530 and
43.20B.020. WSR 98-01-124, § 388-550-2600, filed 12/18/97, effective 1/18/98.]
