Description
The agency is updating the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) chapter to align with guidance from the Centers for Medicare & Medicaid Services.

Agency contacts

Rulemaking contact
Program contact
Rulemaking status history

Preproposal (CR101)

00435: ProviderOne Claims Submission Deadline Changes: Christmas and New Years
Discovery log number
00435
Discovery description

Due to the observance of Christmas and New Year's holidays, ProviderOne claims submission deadlines have been moved up to ensure that providers are able to receive payment and Remittance Advices (RA’s and HIPAA 835 files) on Friday of each impacted week.

The following table details the updated claims submission deadlines for both ProviderOne and the Pharmacy POS systems.

Type

Change

Payment

No Change: Friday, December 27, 2024

Remittance Advice (RAs)/835

No Change: Friday, December 27, 2024

Claims submission deadline - ProviderOne

Changed to 5 p.m. Monday, December 23, 2024

Claims submission deadline – Pharmacy POS

Changed to 5 p.m. Sunday, December 22, 2024

 Week of December 30, 2024

Type

Change

Payment

No Change: Friday, January 3, 2025

Remittance Advice (RAs)/835

No Change: Friday, January 3, 2025

Claims submission deadline - ProviderOne

Changed to 5 p.m. Monday, December 30, 2024

Claims submission deadline – Pharmacy POS

Changed to 5 p.m. Sunday, December 29, 2024

Date reported
ETA
Provider impact
All Providers
Workaround
Please report any issues to: mmishelp@hca.wa.gov.
00434: ProviderOne outage planned for Saturday, December 21, 2024, through Sunday, December 22, 2024
Discovery log number
00434
Discovery description

The ProviderOne system will be unavailable from 5 a.m. Saturday, December 21 until 9 a.m. Sunday, December 22 (28 hours) due to scheduled maintenance.

This outage does not affect the Pharmacy POS

Pharmacies will still be able to submit claims for processing and faxes can be sent during the outage. Faxes will be processed after the outage is complete.

Please report any issues to:  mmishelp@hca.wa.gov.

Thank you.

Date reported
ETA
Provider impact
All Providers
Workaround
Please report any issues to:  mmishelp@hca.wa.gov.
Date closed

Children and youth services

Learn about children and youth services for Apple Health (Medicaid) clients.

What are children and youth services?

Children and youth services are also known as Early Periodic Screening, Diagnosis, and Treatment (EPSDT) and are available for Apple Health clients from birth through 20 years of age.

EPSDT is a free benefit that includes a broad set of health care services, including preventive, dental, mental health, developmental, and specialty care. EPSDT services help ensure children get the health care they need when they need it.

Learn more about EPSDT.

Who can access EPSDT?

EPSDT services are for children and youth birth through 20 years of age who are enrolled in Apple Health coverage.

Parents and caregivers who are under 21 years of age and who are on CN or MN coverage can also access EPSDT services. "Under 21" means through the day before their 21st birthday.

What services are covered?

EPSDT covers services that are medically necessary (WAC 182-500-0070). The broad set of services ensures that your child/youth has access to health care that meets their individual needs. Some covered EPSDT services include:

Other necessary health care services

EPSDT includes diagnostic and treatment services when a health issue is identified. Diagnostic services help you and your health care provider identify what services will address the health issue. This may take place during a well-child checkup or performed outside your regular checkups by a qualified health care provider.

When an issue is identified as a part of a well-child checkup, your health care provider may provide care to address the need or connect you to another provider for additional services.

How to access additional services?

When a child or youth needs a service that is not listed as a covered service or goes beyond the assigned amount of sessions, your health care provider can submit a request for additional services. Requests are reviewed on a case-by-case basis using information specific to your child or youth to determine if the services are medically necessary (WAC 182-501- 0165).

How to find a provider?

Learn how to find a provider and make your first appointment.

Additional services and supports

Description
The agency is amending these rules as an overall housekeeping project. Additionally, the agency is removing definitions for “base year” and “uninsured patient”, removing “with special needs” language from low-income clients, updating the abbreviation of the medicaid inpatient utilization rate from MIPUR to MIUR to align with CMS, updating WAC cross referencing, standardizing language, removing language that the DSH application is posted to the agency’s website, updating that the agency will use the medicare cost report rather than the DRDF to determine a hospital’s MUIR, removing DSH programs no longer funded and not part of the program, and audit requests for additional information must be received 10 days from the initial notification. Also updating the
name of the “provider data summary schedule (PDSS)” to “schedule of annual reporting requirements (SARR).”

Agency contacts

Rulemaking contact
Program contact
Rulemaking status history

Preproposal (CR101)

Proposal (CR102)

Permanent Adoption (CR103P)

Description
The agency is amending these rules to align with RCW 48.43.815; and moving specific revenue categories/subcategories from noncovered to covered.

Agency contacts

Rulemaking contact
Program contact
Rulemaking status history

Preproposal (CR101)

Proposal (CR102)

Permanent Adoption (CR103P)

Description
The agency is amending WAC 182-511-1250 to add detail that will clarify how the agency determines countable income when calculating the program’s premium.

Agency contacts

Rulemaking contact
Program contact
Rulemaking status history

Preproposal (CR101)

Proposal (CR102)

Permanent Adoption (CR103P)