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. (1) Emergency hospital services.

   1. (a) For inpatient hospital claims for emergency services provided in out-of-state hospitals, the agency:

      1. (i) Pays using the same methods used to pay in-state hospitals as specified in this chapter; and
      2. (ii) Calculates the payment using the lowest in-state inpatient hospital rate corresponding to the payment method.

   2. (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:

      1. (i) The agency's outpatient prospective payment system (OPPS) described in WAC 182-550-7000; and

      2. (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:

         1. (A) Billed charges; or
         2. (B) Calculated payment amount.

2. (2) Nonemergency hospital services.

   1. (a) The agency pays for:

      1. (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
      2. (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.

   2. (b) The agency does not pay for:

      1. (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
      2. (ii) Unauthorized nonemergency hospital services are not paid by the agency. See WAC 182-501-0182.
3. (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.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-09-028, § 182-550-4000, filed 4/10/24, effective 5/11/24. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-12-047, § 182-550-4000, filed 5/29/14, effective 7/1/14. WSR 11-14-075, recodified as § 182-550-4000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-063, § 388-550-4000, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090, 74.09.500 and 2005 c 518. WSR 07-14-051, § 388-550-4000, filed 6/28/07, effective 8/1/07. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. WSR 98-01-124, § 388-550-4000, filed 12/18/97, effective 1/18/98.]