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WAC 182-530-7800: Reimbursement—Clients with third-party liability

Published: 2015

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WACs > Title 182 > Chapter 182-530 > Section 182-530-7800



Agency filings affecting this section

WAC 182-530-7800

Reimbursement—Clients with third-party liability.

(1) The department requires providers to meet the third party requirements of WAC 388-501-0200.
(2) The following definitions apply to this section:
(a) "Closed pharmacy network" means an arrangement made by an insurer which restricts prescription coverage to an exclusive list of pharmacies. This arrangement prohibits the coverage and/or payment of prescriptions provided by a pharmacy that is not included on the exclusive list.
(b) "Private point-of-sale (POS) authorization system" means an insurer's system, other than the department's POS system, which requires that coverage be verified by or submitted to the insurer for authorization at the time of service and at the time the prescription is filled.
(3) This subsection applies to clients who have a third-party resource that is a managed care entity other than a department-contracted plan, or have other insurance that requires the use of "closed pharmacy networks" or "private point-of-sale authorization system." The department will not pay pharmacies for prescription drug claims until the pharmacy provider submits an explanation of benefits from the private insurance demonstrating that the pharmacy provider has complied with the terms of the third-party's coverage.
(a) If the private insurer pays a fee based on the incident of care, the pharmacy provider must file a claim with the department consistent with the department's billing requirements.
(b) If the private insurer pays the pharmacy provider a monthly capitation fee for all prescription costs related to the client, the pharmacy provider must submit a claim to the department for the amount of the client copayment, coinsurance, and/or deductible. The department pays the provider the lesser of:
(i) The billed amount; or
(ii) The department's maximum allowable fee for the prescription.
[WSR 11-14-075, recodified as § 182-530-7800, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 07-20-049, § 388-530-7800, filed 9/26/07, effective 11/1/07.]