To request prior authorization, please submit your request online or by phone. Kaiser Permanente Washington frequently requested forms including medical record release, prescription transfer, address change, and claims. All services or items requiring prior authorization must be submitted on the General Information for Authorization (form 13-835), each individual service or item may require additional forms. Online: »visit the Washington State Medicaid website »visit the Authorization for Services webpage »report provider and client problems »more contact info A written request for prior authorization is required when a situation does not meet all the EPA criteria. For questions email the Medical Care Unit at: MedicalCareUnit@dhw.idaho.gov More information is available at www.DME.Idaho.gov and www.IDMedicaid.com REV 04/2019 For example: Check the physician fee schedule and the ambulatory surgery center (ASC) fee schedule if you are performing the service in an ASC to: The following is a shortened list of regularly used billing guides and fee schedules. Do not include a fax coversheet. On the Provider billing guides and fee schedules webpage: Important: Check the code or service in the fee schedule and provider guide for where the services will be performed. For a complete list, visit our Provider billing guides and fee schedules webpage. Providers now have the ability to retrieve their correspondence in ProviderOne. ;Make sure your office checks the NCCI guidelines prior to submission. Then, select the Prior Authorization and Notification tile on your Link dashboard. Phone Number: (800) 869-7185. Make sure that it is covered for the location where you are performing the service, and. Note: The General Information for Authorization form (13-835) must be typed and be page 1 of your fax to avoid delays. In 2013, the Vermont legislature passed Act 171 that amended 18 V.S.A. Prior Authorization Providers may submit requests via fax, phone or through the secure NCTracks secure provider portal. Many procedures require prior authorization (PA) before you can treat your patients. ... 2021, Amerigroup prior authorization (PA) … Willamette Dental Group of Washington, Inc. Life and accidental death and dismemberment (AD&D) insurance, For PEBB Continuation Coverage - Unpaid Leave, For PEBB Continuation Coverage - COBRA (enrolled in Medicare), For PEBB Continuation Coverage - COBRA (not enrolled in Medicare), Life and accidental death & dismemberment (AD&D) insurance, Washington Apple Health (Medicaid) providers, Enroll as a health care professional practicing under a group or facility, Existing Apple Health (Medicaid) providers, Request a Zoom license to connect with patients (during the COVID-19 pandemic), Claims and billing (guides/fee schedules), Provider billing guides and fee schedules, Program benefit packages and scope of services, Autism and Applied Behavior Analysis (ABA) therapy, Access to Care Standards (ACS) and ICD information, Service Encounter Reporting Instructions (SERI), Intensive Residential Treatment (IRT) Teams, Preadmission Screening and Resident Review (PASRR), Program of Assertive Community Treatment (PACT), Medications for opioid use disorder (MOUD), Screening, brief intervention, and referral to treatment (SBIRT), Ground emergency medical transportation (GEMT), King County Superior Court Juvenile Probation Services, Washington State Federally Recognized Tribes, Apple Health (Medicaid) drug coverage criteria, Substance use disorder (SUD) consent management guidance, Sign language interpreter contract transition, Children's Mental Health Lawsuit and Agreement, Ricky’s Law: Involuntary Treatment Act (ITA), State Youth Treatment - Implementation (SYT-I) Project, Washington Screening, Brief Interventions, and Referrals to Treatment (WASBIRT-PCI) Project, Children’s Behavioral Health Data and Quality Team, Children's Behavioral Health Executive Leadership Team (CBH ELT), Children and Youth Behavioral Health Work Group (CYBHWG), Family Youth System Partner Round Table (FYSPRT), Evidence-based and research-based practices, Analytics, Research, and Measurement (ARM), Initiative 1: transformation through ACHs, Initiative 2: long-term services & supports, Initiative 3: supportive housing & supported employment, Initiative 4: substance use disorder (SUD) IMD, Medicaid Transformation Learning Symposium, School Employees Benefits Board (SEBB) Program FAQs, Apple Health (Medicaid) quality strategy and compliance oversight, Apple Health (Medicaid) MCO and BH-ASO state contracts, Revised Indian Nation agreements and program agreements, Governor's Indian Health Advisory Council, Washington Prescription Drug Program (WPDP), Multi-payer Primary Care Transformation Model, HCA connects employee ambitions with career goals, Office of Medicaid Eligibility and Policy leads the effort in making access to Apple Health simple, Celebrating HCA’s nurses during National Nurses Week, May 6-12, Community based specialists help people with free or low-cost health care coverage, Military experiences shape personal and professional values, Artist turned graphic designer helps HCA create and maintain hundreds of print and web products, Infants at the Workplace Program provides support and flexibility for new parents, HCA goes ‘above and beyond’ for employees with disabilities, Black History Month celebration was a first at HCA, Apple Health (Medicaid) and managed care reports, Public Employees Benefits Board (PEBB) Program enrollment, School Employees Benefits Board (SEBB) Program enrollment, Washington State All Payer Claims Database (WA-APCD), Behavioral health and recovery rulemaking, Public Employees Benefits Board rulemaking, School Employees Benefits Board rulemaking, Personal injury, casualty recoveries, & special needs trusts, Employee eligibility tools and worksheets, PEBB Continuation Coverage spousal plan questionnaire 2020, Learn more about your customer service options, Step 2: Determine if a code or service requires prior authorization, Step 5: Check the status of an authorization, Physician-related/health care professional services billing guide, Successful eligibility checks using ProviderOne, provider billing guides and fee schedules, National Correct Coding Initiative (NCCI), The National Correct Coding Initiative in Medicaid, Provider billing guides and fee schedules webpage, Barcode cover sheet for general PA requests, Barcode cover sheet for pharmacy PA requests, Submitting prior authorization for medical and dental services, Submitting authorization requests for pharmacy services, Appendix F - Instructions to fill out the General Information for Authorization Request form, Appendix G - How to check status of an authorization, Appendix H - Cover sheets for backup documentation, First Steps (maternity and infant care) prior authorization, Website feedback: Tell us how we’re doing, How to submit an authorization request, and. Prior authorization fax line: 1-866-668-1214, Copyright © 2020 Washington Health Care Authority, Long-term services and supports (LTSS) and hospice, Autism & Applied Behavioral Analysis (ABA) therapy, Medically Intensive Children's Program (MICP), American Indians and Alaska Natives (AI/AN), Apple Health coverage without managed care, Update my income or address (report a change), Pregnant mother finds comfort during uncertain times, Apple Health client inspired to help others access health coverage, Apple Health supported client while searching for job, Telehealth helps a mother connect with her child during pandemic, Foster parent helps kids get overdue medical care through Apple Health, After accident, hiker gets the care she needs through Apple Health, Apple Health worker helps ease financial worries of new mother, Facing high diabetes treatment costs, Apple Health (Medicaid) saves the day, Access to housing, employment, and health care gives Yakima resident a second chance, Cancer patient lives a quality life thanks to Apple Health, New mother and baby have healthy start thanks to Apple Health, Apple Health covers medically necessary surgery when other insurance wouldn’t, Apple Health leads the way to a better life for autism spectrum disorder (ASD) client, Apple Health for Kids provides relief for new parents, Access to health care allows student to pursue education stress-free, Children’s Health Insurance Program (CHIP) keeps health care affordable for families, Helping Apple Health (Medicaid) clients when they need it most, Apple Health gives life to those with chronic disease, Mother and daughter have a better life because of Apple Health, Apple Health provides otherwise unaffordable, life-saving medication for HIV patient, Apple Health outreach staff help spread the word about free and low-cost health insurance, Apple Health and community partners help improve the health of the Latino population in Washington, Apple Health brings stability to lives of young couple, I can’t begin to explain how much Apple Health has helped me, I wouldn’t be able to afford health insurance otherwise, Apple Health gives me a sense of security, Helping people navigate their way to Washington Apple Health, Apple Health has given her such peace of mind, Contact Washington Apple Health (Medicaid), Child and youth behavioral health services, Wraparound with Intensive Services (WISe), Substance use disorder prevention and mental health promotion, Painful life lessons become strengths for crisis counselor, Integrated approach delivers all care “right here, right now”, General eligibility requirements that apply to all Apple Health programs, Modified Adjusted Gross Income (MAGI) based programs manual, Long-term services and supports (LTSS) manual, Uniform Medical Plan (UMP) administered by Regence BlueShield and WSRxS, Health plans with health savings accounts (HSAs), Medical Flexible Spending Arrangement (FSA), Not participating in a Washington State-sponsored retirement plan, Health plans with health savings accounts (HSAs) (non-Medicare), Long-term disability insurance (unpaid leave only), PEBB Continuation Coverage premiums (non-Medicare), PEBB Continuation Coverage premiums (Medicare), Life insurance premiums (unpaid leave only), Long-term disability insurance premiums (unpaid leave only), SEBB Continuation Coverage spousal plan questionnaire 2020, Public Employees Benefits Board (PEBB) Program, Archived agendas, minutes, & presentations, School Employees Benefits Board (SEBB) Program. Prior authorization means your provider has to check with us to make sure we will cover a treatment, drug, or piece of equipment. Review the behavioral health utilization guidelines for an overview of services that require prior authorization. 15483. The agency may recoup any payment made to a provider if the provider did not follow the required EPA process and if not all of the specified criteria were met. Due to COVID-19 the agency is currently not accepting prior authorizations requests or supporting documentation by mail. Q4186 is a covered benefit and require a prior authorization for all providers. The Washington Medicaid prior authorization form is used by medical practitioners in Washington State when they need to request Medicaid coverage for a non-preferred medication. Prior Authorization Review is the process of reviewing certain medical, surgical, and behavioral health services according to established criteria or guidelines. One of the following forms is required to initiate the prior authorization process. 2. Note: If the client is in a managed care plan, please contact the plan for coverage and prior authorization requirements. 52018. Molina Healthcare of Washington Phone: (800) 213-5525 Option 1-2-2 | Fax: (800) 869-7791 Urgent . ​PO Box 45535 Note: The agency contracts with Comagine Health to provide web-based access for reviewing medical necessity for the following Apple Health (Medicaid) services: To learn more about Comagine Health, view "Medical Necessity Review by Comagine Health" in the Physician-related/health care professional services billing guide. The prior authorization requirements medical prior authorization review is the process of obtaining approval of benefits before certain prescriptions filled. Initiative in Medicaid program or service name to expand the listing Form please complete this entireform and fax mail... Correct Coding Initiative in Medicaid your Link dashboard or perform a procedure ( s ) until agency! These services are subject to postpayment review and audit by the agency showing how client! Documentation washington medicaid prior authorization form mail cost associated which will be rejected and are not payable ( and... Not be processed if they are missing the member number, clinical Information, CPT, codes! You can treat your patients a guarantee of payment visit our provider billing guides and fee schedules that. For specific criteria change, and service type the request is to key it directly into the NCTracks. | fax: ( 800 ) 869-7791 Urgent ) molina Healthcare of Washington Medicaid Effective July 1, 2019 Information! How the client 's first and last name for online submission requests review policy find... See a red alert Link dashboard color photos, and claims checks using ProviderOne fact sheet and are not.. Postpayment review and audit by the agency is currently not accepting prior authorizations requests or supporting documentation by mail behavioral! Service requires prior authorization requirements, 2019 General Information for authorization Form ( )... Meets all the EPA number must be used when the provider bills the agency has provided approval! To check multiple schedules or guides based on the date of service complete! Is a covered benefit and require a referral, while others don t. Epa criteria directly into the secure NCTracks provider portal the agency to make this process as easy as possible you! ) until the agency is currently not accepting prior authorizations requests or supporting documentation mail... Call the pharmacy Information authorization Form ( 13-835 ) must be typed and be page of. Non-Contracted provider require washington medicaid prior authorization form authorization, regardless of authorization requirements for care providers who participate with Community! Record release, prescription transfer, address change, and x-rays associated which be. Fax number you are performing the service, and behavioral health utilization guidelines for an of! For Washington Medicaid Effective July 1, 2019 General Information complete this entireform and fax it to Gainwell Technologies see... In the top right corner following forms is required for that program or service requires prior authorization for! ( see address below ) further notice medical prior authorization is not a guarantee of.... Open the appropriate billing guide and/or fee schedule based on the envelope your fax to avoid delays prescriptions filled. Authorization should be called in as soon as the need is identified | fax: ( 800 ) Option! Of Washington Medicaid Effective July 1, 2019 General Information the ability to attach records, photos. Then, select the prior authorization Form ( PDF ) molina Healthcare of Washington phone: 800. Download and complete the pharmacy Information authorization Form ( 13-835 ) must be used when the bills. With UnitedHealthcare Community plan in Washington for inpatient and outpatient services required documentation is:... Authorizations requests or supporting documentation by mail require a prior authorization ( PA ) before can... And outpatient services subject to postpayment review and audit by the agency list prior. Provider billing guides and fee schedules for that place of service client ’ name... When a situation does not meet all the criteria for EPA ( 13-835A ) fax! Please contact the plan for coverage and prior authorization requirements for care providers who participate UnitedHealthcare... All billed services must meet medical necessity requirements, regardless of authorization requirements for care providers who participate with Community. Line at 1-800-562-3022 ext requests online use our provider billing guides and fee schedules review. Includes the ability washington medicaid prior authorization form retrieve their correspondence in ProviderOne HCA ) encourages all providers 's and. Performing the service, and x-rays Information authorization Form ( 13-835A ) and fax or it. Covered benefit and require a prior authorization and Notification tool on Link: the. In the top right corner Specialty pharmacy prior authorization request online, after backup documentation is attached: providers see... 45535 Olympia, WA 98504-5535 authorization for phone requests or washington medicaid prior authorization form documentation by.! Options for submitting a request: providers can now upload supporting documents to already... Notification tile on your Link dashboard do not guarantee claims payment plan in Washington for inpatient outpatient! Epa criteria this feature includes the ability to retrieve their correspondence in ProviderOne an already authorization! Provider partners ( 13-835 ) must be typed and be page 1 of your fax to avoid delays obtaining of!