WAC 182-550-4000. Payment method — Out-of-state hospitals

This section describes the payment methods the agency uses to pay hospitals located out-of-state for providing services to eligible Washington apple health clients. This section does not apply to hospitals located in any of the designated bordering cities listed in WAC 182-501-0175 . Payment methods that apply to bordering city hospitals, including critical border hospitals, are described in WAC 182-550-3900 . See also WAC 182-501-0180 , health care services provided outside the state of Washington - General provisions, and WAC 182-502-0120 , payment for health care services provided outside the state of Washington. (1) Emergency hospital services. (a) For inpatient hospital claims for emergency services provided in out-of-state hospitals, the agency: (i) Pays using the same methods used to pay in-state hospitals as specified in this chapter; and (ii) Calculates the payment using the lowest in-state inpatient hospital rate corresponding to the payment method. (b) For outpatient hospital claims for emergency services provided in out-of-state hospitals, the agency pays an out-of-state hospital using the following methods: (i) The agency's outpatient prospective payment system (OPPS) described in WAC 182-550-7000 ; and (ii) The maximum allowable fee schedule method described in WAC 182-550-6000 . When the maximum allowable fee schedule method is used, the agency limits payment to the lesser of the: (A) Billed charges; or (B) Calculated payment amount. (2) Nonemergency hospital services. (a) The agency pays for: (i) Contracted and prior authorized nonemergency hospital services according to the contract terms whether or not the hospital has signed a core provider agreement; and (ii) Nonemergency hospital services authorized by the agency after the fact (subsequent to the date of admission, if the client is still at the out-of-state hospital, or after the services have been provided) according to subsections (1) and (3) of this section. (b) The agency does not pay for: (i) Nonemergency hospital services provided to a Washington apple health client in a hospital located out-of-state unless the hospital is contracted and prior authorized by the agency or the agency's designee for the specific service provided to a specific client; and (ii) Unauthorized nonemergency hospital services are not paid by the agency. See WAC 182-501-0182 . (3) The agency makes claim payment adjustments including, but not limited to, client responsibility, third-party liability, and medicare. All applicable adjustments are factored into the final hospital payment amount.