WAC 182-543-0500 General

WAC 182-543-0500 General.

Revised May 26, 2021

1. The federal government considers medical equipment, supplies, and appliances, which the medicaid agency refers to throughout this chapter as medical equipment, services under the medicaid program.
2. The agency pays for medical equipment, including modifications, accessories, and repairs, according to agency rules and subject to the limitations and requirements in this chapter when the medical equipment is:
   1. Medically necessary, as defined in WAC 182-500-0070;
   2. Authorized, as required within this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions and provider notices; and
   3. Billed according to this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions and provider notices.
3. For the initiation of medical equipment under WAC 182-551-2122, the face-to-face encounter must be related to the primary reason the client requires medical equipment and must occur no later than six months prior to the start of services.
4. The face-to-face encounter may be conducted by:
   1. A physician;
   2. A nurse practitioner;
   3. A clinical nurse specialist;
   4. A certified nurse midwife under 42 C.F.R 440.70 when furnished by a home health agency that meets the conditions of participation for medicare;
   5. A physician assistant; or
   6. The attending acute, or post-acute physician, for beneficiaries admitted to home health immediately after an acute or post-acute stay.
5. Services may be ordered by:
   1. Physicians;
   2. Nurse practitioners;
   3. Clinical nurse specialists; or
   4. Physician assistants.
6. The agency requires prior authorization for covered medical equipment when the clinical criteria set forth in this chapter are not met, including the criteria associated with the expedited prior authorization process.
   1. The agency evaluates requests requiring prior authorization on a case-by-case basis to determine medical necessity as defined in WAC 182-500-0070, according to the process found in WAC 182-501-0165.
   2. Refer to WAC 182-543-7000, 182-543-7100, 182-543-7200, and 182-543-7300 for specific details regarding authorization.
7. The agency bases its determination about which medical equipment requires prior authorization (PA) or expedited prior authorization (EPA) on utilization criteria (see WAC 182-543-7100 for PA and WAC 182-543-7300 for EPA). The agency considers all of the following when establishing utilization criteria:
   1. Cost;
   2. The potential for utilization abuse;
   3. A narrow therapeutic indication; and
   4. Safety.
8. The agency evaluates a request for equipment that does not meet the definition of medical equipment or that is determined not medically necessary under the provisions of WAC 182-501-0160. When early and periodic screening, diagnosis and treatment (EPSDT) applies, the agency evaluates a noncovered service, equipment, or supply according to the process in WAC 182-501-0165 to determine if it is medically necessary, safe, effective, and not experimental (see WAC 182-543-0100 for EPSDT rules).
9. The agency may terminate a provider's participation with the agency according to WAC 182-502-0030 and 182-502-0040.
10. The agency evaluates a request for a service that meets the definition of medical equipment but has been determined to be experimental or investigational, under the provisions of WAC 182-501-0165.
11. If the agency denies a requested service, the agency notifies the client in writing that the client may request an administrative hearing under chapter 182-526 WAC. (For MCO enrollees, see WAC 182-538-110.)