WAC 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 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 an administrative hearing under chapter 182-526 WAC. After receiving a request for an administrative 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) An administrative hearing conducted according to chapter 182-526 WAC. (4) The agency may authorize an administrative day rate payment, 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.