Section 182-501-0163. Health care coverage—Process for submitting a valid request for authorization.

(1) The medicaid agency requires providers to obtain authorization for certain health care services under this section, chapters 182-501 and 182-502 WAC, other applicable agency rules, current published agency billing instructions, and numbered memoranda. For the purposes of this section, health care services include treatment, equipment, related supplies, and drugs.

(a) For health care services that require prior authorization (PA), a provider (as defined in WAC 182-500-0085) must submit a written, electronic, or telephonic request to the agency. To be a valid request for PA, the provider must send the request and follow the agency's current published program billing instructions, numbered memoranda, and any additional requirements in Washington Administrative Code (WAC) and Revised Code of Washington (RCW).

(b) For expedited prior authorization (EPA), a provider must certify that the client's clinical condition meets the appropriate EPA criteria outlined in the agency's current published program billing instructions, numbered memoranda, and any additional requirements in WAC and RCW. The provider must use the agency-assigned EPA number when submitting a claim for payment to the agency.

(c) The agency requires PA for covered health care services when the applicable EPA criteria are not met.

(d) Upon request, a provider must send documentation to the agency showing how the client's condition meets the required criteria for PA or EPA.

(2) Agency authorization requirements for covered health care services are not a denial of service.

(3) The agency returns invalid requests to the provider and takes no further action unless the request for authorization is resubmitted. The return of an invalid request is not a denial of service.

(4) Failure of a provider to request authorization for a health care service that requires it or a provider's failure to do so properly is not a denial of service.

(5) The agency's authorization of health care services does not guarantee payment. See WAC 182-501-0050 for other general requirements that must be satisfied before payment can be made for a health care service requested and authorized under this section.

(6) The agency evaluates a request for authorization of a health care service that exceeds identified limitations on a case-by-case basis and under WAC 182-501-0169.

(7) The agency may recoup any payment made to a provider if the agency later determines the health care service was not properly authorized or did not meet EPA criteria. See chapters 182-502 and 182-502A WAC.

[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 15-15-053, § 182-501-0163, filed 7/9/15, effective 8/9/15. WSR 11-14-075, recodified as § 182-501-0163, 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 09-23-112, § 388-501-0163, filed 11/18/09, effective 12/19/09.]

RCW 41.05.021 and 41.05.160. WSR 15-15-053, § 182-501-0163, filed 7/9/15, effective 8/9/15. WSR 11-14-075, recodified as § 182-501-0163, 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 09-23-112, § 388-501-0163, filed 11/18/09, effective 12/19/09.

Rules

182-501,182-502,182-500-0085,182-501-0050,182-501-0169,182-502,182-502A,