Health care—General policy.
The policy of the department of corrections (the department) with regard to health care for offenders in adult correctional facilities is to provide that care, consistent with the Offender Health Plan (OHP), which is medically necessary to respond to the offender's medical, dental, and mental health needs. Medically necessary is defined as that care that is determined by the department to:
• | Be consistent with applicable department policies and procedures; |
• | Be ordered by an authorized department health care provider; |
• | Not be considered experimental or be lacking in medically recognized professional documentation of efficacy; and |
• | Not be administered solely for the convenience of the offender or the health care provider. |
[WSR 11-01-149, § 137-91-010, filed 12/21/10, effective 1/21/11. WSR 97-22-057, § 137-91-010, filed 11/3/97, effective 10/22/97.]
Reviser's note: Under RCW
34.05.030 (1)(c), as amended by section 103, chapter 288, Laws of 1988, the above section was not adopted under the Administrative Procedure Act, chapter
34.05 RCW, but was published in the Washington State Register and codified into the Washington Administrative Code exactly as shown by the agency filing with history notes added by the code reviser's office.
Contracts for services.
The department intends to purchase health care in a prudent, cost-effective manner without unduly restricting offenders' access to appropriate and medically necessary care. Therefore, notwithstanding any other provisions of law, the secretary may enter into contracts with health care practitioners, health care facilities, and other entities or agents qualified to provide such services as may be necessary to provide health care to offenders in accordance with the provisions of RCW
72.10.030.
[WSR 97-22-057, § 137-91-020, filed 11/3/97, effective 10/22/97.]
Reviser's note: Under RCW
34.05.030 (1)(c), as amended by section 103, chapter 288, Laws of 1988, the above section was not adopted under the Administrative Procedure Act, chapter
34.05 RCW, but was published in the Washington State Register and codified into the Washington Administrative Code exactly as shown by the agency filing with history notes added by the code reviser's office.
Utilization review.
When purchasing health care services and establishing medical necessity of services, the secretary is authorized to implement health care utilization management methods to assure the appropriateness of the care rendered to the offender. These methods may include but are not limited to: Prior authorization; hospital length of stay review; case management; treatment guidelines; and audit of billed charges and services rendered.
[WSR 97-22-057, § 137-91-030, filed 11/3/97, effective 10/22/97.]
Reviser's note: Under RCW
34.05.030 (1)(c), as amended by section 103, chapter 288, Laws of 1988, the above section was not adopted under the Administrative Procedure Act, chapter
34.05 RCW, but was published in the Washington State Register and codified into the Washington Administrative Code exactly as shown by the agency filing with history notes added by the code reviser's office.
Purchasing health care services.
The secretary is authorized to institute any reasonable reimbursement mechanism for purchasing health care services from health care practitioners or health care facilities. These reimbursement mechanisms shall include, but are not limited to: Capitation; per diems, global fees; diagnosis-related groups (DRG); fee schedules, or any other prudent cost-effective payment method which shall be established by rule adopted in accordance with chapter
34.05 RCW.
[WSR 97-22-057, § 137-91-040, filed 11/3/97, effective 10/22/97.]
Reviser's note: Under RCW
34.05.030 (1)(c), as amended by section 103, chapter 288, Laws of 1988, the above section was not adopted under the Administrative Procedure Act, chapter
34.05 RCW, but was published in the Washington State Register and codified into the Washington Administrative Code exactly as shown by the agency filing with history notes added by the code reviser's office.
Audits and recovery in purchasing health care services.
The secretary may establish rules and procedures for selectively and/or randomly auditing the accuracy of fees and the medical billings submitted to the department. The department, or its agent, may review the offender's community health care record to assure that the offender received the services for which the bill was submitted.
Whenever an audit establishes that the services rendered were not authorized or medically necessary, the department shall not pay the cost for such services nor shall the offender be held accountable for such costs.
The secretary is authorized to seek recovery when the department identifies that a health care practitioner or facility is not entitled to the billed fees. The practitioner or facility is liable for any excess payment received and must repay the excess payment plus accrued interest on the excess payment at the rate of one percent per month for each month for the period from the date which the payment was made to the date upon which payment is made to the department.
[WSR 97-22-057, § 137-91-050, filed 11/3/97, effective 12/5/97. Statutory Authority: RCW
72.01.050,
72.01.090 and
72.09.050. WSR 84-16-066 (Order 84-11), § 137-91-050, filed 7/30/84, effective 9/4/84. Formerly WAC 275-91-050.]
Reviser's note: Under RCW
34.05.030 (1)(c), as amended by section 103, chapter 288, Laws of 1988, the above section was not adopted under the Administrative Procedure Act, chapter
34.05 RCW, but was published in the Washington State Register and codified into the Washington Administrative Code exactly as shown by the agency filing with history notes added by the code reviser's office.
Other health care coverage.
If an offender is eligible for health care benefits through the veterans administration, the department of labor and industries (L&I), automobile insurance claims, or any other third-party payer or insurer determined to be primarily responsible for the offender's health condition, through coordination of benefits rules, the department of corrections shall be considered a secondary payer.
[WSR 97-22-057, § 137-91-075, filed 11/3/97, effective 10/22/97.]
Reviser's note: Under RCW
34.05.030 (1)(c), as amended by section 103, chapter 288, Laws of 1988, the above section was not adopted under the Administrative Procedure Act, chapter
34.05 RCW, but was published in the Washington State Register and codified into the Washington Administrative Code exactly as shown by the agency filing with history notes added by the code reviser's office.
Health care services.
The health care program operated by the department of corrections shall include the following services:
(1) Initial examination when the offender enters the adult correction system. This examination shall include:
(a) Health history;
(b) An initial physical examination including laboratory, radiology and other diagnostic studies, as indicated;
(c) Dental examination;
(2) Immunizations, as indicated;
(3) Evaluation of capacity for work, educational programs, special housing assignment, and recreation;
(4) Consultations, examinations and treatment as required for the health maintenance of each offender in accordance with the policy discussed at WAC
137-91-010.
[WSR 97-22-057, § 137-91-080, filed 11/3/97, effective 12/5/97. WSR 96-21-014, § 137-91-080, filed 10/4/96, effective 11/5/96.]
Reviser's note: Under RCW
34.05.030 (1)(c), as amended by section 103, chapter 288, Laws of 1988, the above section was not adopted under the Administrative Procedure Act, chapter
34.05 RCW, but was published in the Washington State Register and codified into the Washington Administrative Code exactly as shown by the agency filing with history notes added by the code reviser's office.
Use of allied health professionals.
Allied health professionals, those licensed certified or registered health care providers other than physicians or dentists, may be used in the health care programs at each correctional facility. Allied health professionals may deliver such care as their licensure, certification, registration or statute governing their profession permits.
[WSR 97-22-057, § 137-91-090, filed 11/3/97, effective 10/22/97.]
Reviser's note: Under RCW
34.05.030 (1)(c), as amended by section 103, chapter 288, Laws of 1988, the above section was not adopted under the Administrative Procedure Act, chapter
34.05 RCW, but was published in the Washington State Register and codified into the Washington Administrative Code exactly as shown by the agency filing with history notes added by the code reviser's office.
Health record.
The health record shall be maintained at the facility where an offender is housed. Health records of offenders housed at work release facilities shall be maintained at a location(s) designated by the regional administrator for the region in which the facility is located. Upon transfer of the offender between state facilities, that offender's record shall be transferred along with the offender. The health record shall be archived ninety days following the offender's release from the department's jurisdiction. The health record shall include:
(1) Detailed reports of admission, medical, dental and mental health evaluations and recommendations;
(2) All primary encounter and progress notes regarding continuing health status including illnesses, hospitalization, surgery, results of consultations and examinations, reports of tests done, immunizations, and problem lists;
(3) Reports completed by outside consultants.
Information contained in the offender health record is
confidential. Access to and release of information contained in the offender health record shall be in strict compliance with chapter
70.02 RCW.
[WSR 03-16-072, § 137-91-100, filed 8/4/03, effective 9/4/03. WSR 97-22-057, § 137-91-100, filed 11/3/97, effective 10/22/97.]
Reviser's note: Under RCW
34.05.030 (1)(c), as amended by section 103, chapter 288, Laws of 1988, the above section was not adopted under the Administrative Procedure Act, chapter
34.05 RCW, but was published in the Washington State Register and codified into the Washington Administrative Code exactly as shown by the agency filing with history notes added by the code reviser's office.
