WAC 182-501-0135 Patient review and coordination (PRC).

1.  Patient review and coordination (PRC) program, formerly known as the patient review and restriction (PRR) program, coordinates care and ensures that clients selected for enrollment in PRC use services appropriately and in accordance with department rules and policies. 

a.  PRC applies to medical assistance fee-for-service and managed care clients.  PRC does not apply to clients eligible for the family planning only program.

b.  PRC is authorized under federal Medicaid law by 42 USC 1396n(a)(2) and 42 CFR 431.54.

2.  Definitions.   The following definitions apply to this section only:

"Appropriate use" - Use of healthcare services that are adapted to or appropriate for a client's healthcare needs.

"Assigned provider" - A department-enrolled healthcare provider or one participating with a department contracted managed care organization (MCO) who agrees to be assigned as a primary provider and coordinator of services for a fee-for-service or managed care client in the PRC program. Assigned providers can include a primary care provider (PCP), a pharmacy, a controlled substances prescriber, and a hospital for nonemergent hospital services. 

"At-risk " - a term used to describe one or more of the following:

a.  A client with a medical history of:

b.  Behaviors or practices that could jeopardize a client's medical treatment or health including, but not limited to:

"Care management" - Services provided to clients with multiple health, behavioral, and social needs in order to improve care coordination, client education, and client self-management skills. 

"Client" - A person enrolled in a department healthcare program and receiving service from fee-for-services provider(s) or a managed care organization (MCO), contracted with the department.

"Conflicting" - Drugs and/or healthcare services that are incompatible and/or unsuitable for use together because of undesirable chemical or physiological effects.

"Contraindicated" - To indicate or show a medical treatment or procedure is inadvisable or not recommended or warranted.

"Controlled substances prescriber" - Any of the following healthcare professionals who, within their scope of professional practice, are licensed to prescribe and administer controlled substances (see chapter 69.50 RCW, Uniform Controlled Substance Act) for a legitimate medical purpose:

"Duplicative" - Applies to the use of the same or similar drugs and healthcare services without due justification.  Example:  A client receives healthcare services from two or more providers for the same or similar conditions(s) in an overlapping time frame, or the client receives two or more similarly acting drugs in an overlapping time frame, which could result in a harmful drug interaction or an adverse reaction.

"Just cause" - A legitimate reason to justify the action taken, including but not limited to, protecting the health and safety of the client.

"Managed care organization" or "MCO" - An organization having a certificate of authority or certificate of registration from the Office of Insurance Commissioner, that contracts with the department under a comprehensive risk contract to provide prepaid healthcare services to eligible medical assistance clients under the department's managed care programs.

"Managed care client" - A medical assistance client enrolled in, and receiving healthcare services from, a department-contracted managed care organization (MCO).

"Primary care provider" or "PCP" - A person licensed or certified under title 18 RCW including, but not limited to, a physician, an advanced registered nurse practitioner (ARNP), or a physician assistant who supervises, coordinates, and provides healthcare services to a client, initiates referrals for specialty and ancillary care, and maintains the client's continuity of care.

3.  Clients selected for PRC review.  The department or MCO selects a client for PRC review when either or both of the following occur:

a.  A utilization review report indicates the client has not utilized healthcare services appropriately; or

b.  Medical providers, social service agencies, or other concerned parties have provided direct referrals to the department or MCO.

4.  When a fee-for-service client is selected for PRC review the prior authorization process as defined in chapter 388-530 WAC may be required:

a.  Prior to or during a PRC review; or

b.  When currently in the PRC program.

5.  Review for placement in the PRC program.  When the department or MCO selects a client for PRC review, the department or MCO staff, with clinical oversight, reviews a client's medical and/or billing history to determine if the client has utilized healthcare services at a frequency or amount that is not medically necessary (42 CFR 431.54(e)).

6.  Utilization guidelines for PRC placement.  Department or MCO staff use the following utilization guidelines to determine PRC placement.  A client may be placed in the PRC program when medical and/or billing histories document any of the following:

a.  Any two or more of the following conditions occurred in a period of ninety consecutive calendar days in the previous twelve months.  The client:

i.  Received services from four or more different providers, including physicians, advanced registered nurse practitioners (ARNPs), and physician assistants (PAs);

ii.  Had prescriptions filled by four or more different pharmacies;

iii.  Received ten or more prescriptions;

iv.  Had prescriptions written by four or more different prescribers;

v.  Received similar services from two or more providers in the same day; or

vi.  Had ten or more office visits.

b.  Any one of the following occurred within  period of ninety consecutive calendar days in the previous twelve months.  The client:

i.  Made two or more emergency department visits;

ii.  Has a medical history that indicates "at-risk" utilization patterns;

iii.  Made repeated and documented efforts to seek healthcare services that are not medically necessary; or

iv.  Has been counseled at least once by a health care provider, or a department or MCO staff member, with clinical oversight, about the appropriate use of healthcare services.

c.  The client received prescriptions for controlled substances from two or more different prescribers in any one month in a period ninety consecutive days in the previous twelve months.

d.  The client's medical and/or billing history demonstrates a pattern of the following at any time in the previous twelve months:

i.  The client has a history of using healthcare services in a manner that is duplicative, excessive, or contraindicated; or

ii.  The client has a history of receiving conflicting healthcare services, drugs, or supplies that are not within acceptable medical practice.

7.  PRC review results.  As a result of the PRC review, the department or MCO staff may take any of the following steps:

a.  Determine that no action is needed and close the client's file;

b.  Send the client and, if applicable, the client's authorized representative, a letter of concern with the information on specific findings and notice of potential placement in the PRC program; or

c.  Determine that the utilization guidelines for PRC placement establish that the client has utilized healthcare services at an amount or frequency that is not medically necessary, in which case, the department or MCO will take one or more of the following actions:

i.  Refer the client for education on appropriate use of healthcare services;

ii. Refer the client to other support services or agencies; or

iii. Place the client into the PRC program for an initial placement period of twenty-four months.

8.  Initial placement in th ePRC program.  When a client is initially placed in the PRC program:

a.  The department or MCO places the client for twenty-four months with one or more of the following types of healthcare providers:

i.  Primary care provider (PCP) (as defined in subsection 2 of this section);

ii.  Pharmacy;

iii.  Controlled substances prescriber;

iv.  Hospital (for nonemergent hospital services); or

v.  Another qualified provider type, as determined by department or MCO program staff on a case-by-case basis.

b.  The managed care client will remain in the same MCO for no less than twelve months unless:

i.  The client moves to a residence outside the MCO's service area and the MCO is not available in the new location; or

ii.  The client's assigned provider no longer participates with the MCO and is available in another MCO, and the client wishes to remain with the current provider.

c.  A managed care client placed in the PRC program must remain the PRC program for the initial twenty-four month period regardless of whether the client changes MCOs or becomes a fee-for-service client.

d.  A care management program may be offered to a client.

9.  Notifying the client about placement in the PRC program.  When the client is initially placed in the PRC program, the department or the MCO sends the client and, if applicable, the client's authorized representative, a written notice containing at least the following components:

a.  Informs the client of the reason for the PRC program placement;

b.  Directs the client to respond to the department or MCO within ten business days of the date of the written notice about taking the following actions;

i.  Select providers, subject to department or MCO approval;

ii.  Submit additional healthcare information, justifying the client's use of healthcare services; or

iii.  Request assistance, if needed, from the department or MCO program staff.

c.  Informs the client of hearing or appeal rights (see subsection 14 of this section).

d.  Informs the client that if a response is not received within ten days of the date of the notice, the client will be assigned a provider(s) by the department or MCO;.

10.  Selection and role of assigned provider.  A client may be afforded a limited choice of providers.

a.  The following providers are not available:

i.  A provider who is being reviewed by the department or licensing authority regarding quality of care;

ii.  A provider who has been suspended or disqualified from participating as a department-enrolled  or MCO-contracted provider; or

iii. A provider whose business license is suspended or revoked by the licensing authority.

b.  For a client placed in the PRC program, the assigned:

i.  Provider(s) must be located in the client's local geographic area, in the client's selected MCO, and/or be reasonably accessible to the client.

ii.  Primary care provider (PCP) supervises and coordinates healthcare services for the client, including continuity of care and referrals to specialists when necessary.  The PCP must be one of the following:

A.  A physician who meets the criteria as defined in chapter 388-502 WAC;

B.  An advanced registered nurse practitioner (ARNP) who meets the criteria as defined in chapter 388-502 WAC; or

C.  A licensed physician assistant (PA), practicing with a supervising physician.

iii.  Controlled substances prescriber prescribes all controlled substances for the client.

iv.  Pharmacy fills all prescriptions for the client.

v.  Hospital provides all nonemergent hospital services.

c.  A client placed in the PRC program cannot change assigned providers for twelve months after the assignments are made, unless:

i.  The client moves to a residence outside the provider's geographic area;

ii.  The provider moves out of the client's local geographic area and is no longer reasonably accessible to the client;

iii. The provider refuses to continue to serve the client;

iv.  The client did not select the provider.  The client may request to change an assigned provider once within thirty calendar days of the initial assignment;

v.  The client's assigned provider no longer participates with the MCO.  In this case, the client may select a new provider from the list of available providers in the MCO or follow the assigned provider to the new MCO.

d.  When an assigned prescribing provider no longer contracts with the department:

i.  All prescriptions from the provider are invalid thirty calendar days following the date the contract ends; and

ii.  All prescriptions from the provider are subject to applicable prescription drugs (outpatient) rules in chapter 388-530 WAC or appropriate MCO rules.

iii.  The client must choose or be assigned another provider according to the requirements in this section.

11.  PRC placement periods.   The length of time for a client's PRC placement includes:

a.  The initial period of PRC placement, which is a minimum of twenty-four consecutive months.

b.  The second period of PRC placement, which is an additional thirty-six consecutive months.

c.  The third period and each subsequent period of PRC placement, which is an additional seventy-two months.

12.  Department review of a PRC placement period.  The department or MCO reviews a client's use of healthcare services prior to the end of each PRC placement period described in subsection 11 of this section using the utilization guidelines in subsection 6 of this section.

a.  The department or MCO assigns the next PRC placement period if the utilization guidelines for PRC placement in subsection 6 apply to the client.

b.  When the department or MCO assigns a subsequent PRC placement period, the department or MCO sends the client and, if applicable, the client's authorized representative, a written notice informing the client:

i.  The reason for the subsequent PRC program placement;

ii.  The length of the subsequent PRC placement;

iii.   That the current providers assigned to the client continue to be assigned to the client during the subsequent PRC placement period;

iv.  That all PRC program rules continue to apply; and

v.  Of hearing or appeal rights (see subsection 14 of this section);

vi.  Of the rules that support the decision.

c.  The department may remove a client from PRC placement if the client:

i.  Successfully completes a treatment program that is provided by a chemical dependency service provider certified by the department under chapter 388-805 WAC;

ii.  Submits documentation of completion of the approved treatment program to the department; and

iii.  Maintains appropriate use of healthcare services within the utilization guidelines described in subsection 6 for six months after the date the treatment ends.

d.  The department  or MCO determines the appropriate placement period for a client who has been placed back into the program.

e.  A client will remain placed in the PRC program regardless of change in eligibility program type or change in address.

13.  Client financial responsibility.  A client placed in the PRC program may be billed by a provider and held financially responsible for healthcare services when the client obtains nonemergent services and the provider who renders the services is not assigned or referred under the PRC program.

14.  Right to hearing or appeal. 

a.  A fee-for-service client who believes the department has taken an invalid action pursuant to this section may request a hearing.

b.  A managed care client who believes the MCO has taken an invalid action pursuant to this section or chapter 388-538 WAC must exhaust the MCO's internal appeal process set forth in WAC 388-538-110  prior to requesting a hearing.  Managed care clients can not change MCOs until the appeal or hearing is resolved and there is a final ruling.

c.  A client must request the hearing or appeal within ninety calendar days after the client receives the written notice of placement in the PRC program. 

d.  The department conducts a hearing according to chapter 388-02 WAC.  Definitions for the terms "hearing," initial order," and "final order" used in this subsection are found in WAC 388-02-0010.

e.  A client who requests a hearing or appeal within ten calendar days from the date of the written notice of an initial PRC placement period under subsection 11(a) of this section will not be placed in the PRC program until the date an initial order is issued that supports the client's placement in the PRC program or otherwise ordered by an administrative law judge (ALJ).

f.  A client who requests a hearing or appeal more than ten calendar days from the date of the written notice under subsection 9 of this section will remain placed in the PRC program unless a final administrative order is entered that orders the client's removal from the program.

g.  A client who requests a hearing or appeal within ninety days from the date of receiving the written notice under subsection 9 of this section and who has already been assigned providers will remain placed in the PRC program unless a final administrative order is entered that orders the client's removal from the program.

h.  An administrative law judge (ALJ) may rule that the client be placed in the PRC program prior to the date the record is closed and prior to the date the initial order is issued based on a showing of just cause.

i.  The client who requests a hearing challenging placement into the PRC program has the burden of proving the department's or MCO's action was invalid.  For standard of proof, see WAC 388-02-0485.