Section 182-550-2590 - Agency prior authorization requirements for Level 1 and Level 2 LTAC services(1) The medicaid agency requires prior authorization for Level 1 and Level 2 long term acute care (LTAC) inpatient stays. The prior authorization process includes all the following:(a) For an initial 30-day stay: (i) The client must: (A) Be eligible under one of the programs listed in WAC 182-550-2575; and(B) Require Level 1 or Level 2 LTAC services as defined in WAC 182-550-1050.(ii) The LTAC provider of services must:(A) Before admitting the client to the LTAC hospital, submit a request for prior authorization to the agency by fax, electronic mail, or telephone, as published in the agency's LTAC billing instructions;(B) Include sufficient medical information to justify the requested initial stay;(C) Obtain prior authorization from the agency's medical director or designee, when accepting the client from the transferring hospital; and(D) Meet all the requirements in WAC 182-550-2580.(b) For any extension of stay, the criteria in (a) of this subsection must be met, and the LTAC provider of services must submit a request for the extension of stay to the agency with sufficient medical justification.(2) The agency authorizes Level 1 or Level 2 LTAC services for initial stays or extensions of stay based on the client's circumstances and the medical justification received.(3) A client who does not agree with a decision regarding a length of stay has a right to a fair hearing under chapter 182-526 WAC. After receiving a request for a fair hearing, the agency may request additional information from the client and the facility, or both. After the agency reviews the available information, the result may be: (a) A reversal of the initial agency decision;(b) Resolution of the client's issue(s); or(c) A fair hearing conducted according to chapter 182-526 WAC.(4) The agency may authorize an administrative day rate payment, as well as payment for medically necessary ancillary services as determined by the agency, pharmacy services, and pharmaceuticals, for a client who meets one or more of the following. The client:(a) Does not meet the requirements for Level 1 or Level 2 LTAC services;(b) Is waiting for placement in another hospital or other facility; or(c) If appropriate, is waiting to be discharged to the client's residence.Wash. Admin. Code § 182-550-2590
Amended by WSR 15-18-065, Filed 8/27/2015, effective 9/27/2015Amended by WSR 19-18-026, Filed 8/28/2019, effective 9/28/2019Amended by WSR 23-21-063, Filed 10/12/2023, effective 1/1/202411-14-075, recodified as §182-550-2590, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.09.500. 08-21-039, § 388-550-2590, filed 10/8/08, effective 11/8/08; 07-11-129, § 388-550-2590, filed 5/22/07, effective 8/1/07. Statutory Authority: RCW 74.08.090. 02-14-162, § 388-550-2590, filed 7/3/02, effective 8/3/02.