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Washington Administrative Code (Last Updated: November 23, 2016) |
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Title 182. Health Care Authority |
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Chapter 182-544. Vision care. |
Section 182-544-0560. Vision care—Authorization.
Latest version.
- (1) The department requires providers to obtain authorization for covered vision care services as required in this chapter, chapters 388-501 and 388-502 WAC, and in published department billing instructions and/or numbered memoranda or when the clinical criteria required in this chapter are not met.(a) For prior authorization (PA), a provider must submit a written request to the department as specified in the department's published vision care billing instructions.(b) For expedited prior authorization (EPA), a provider must meet the clinically appropriate EPA criteria outlined in the department's published vision care billing instructions. The appropriate EPA number must be used when the provider bills the department.(c) Upon request, a provider must provide documentation to the department showing how the client's condition met the criteria for PA or EPA.(2) Authorization requirements in this chapter are not a denial of service.(3) When a service requires authorization, the provider must properly request authorization in accordance with the department's rules, billing instructions, and numbered memoranda.(4) When authorization is not properly requested, the department rejects and returns the request to the provider for further action. The department does not consider the rejection of the request to be a denial of service.(5) The department's authorization of service(s) does not necessarily guarantee payment.(6) The department evaluates requests for authorization of covered vision care services that exceed limitations in this chapter on a case-by-case basis in accordance with WAC 388-501-0169.(7) The department may recoup any payment made to a provider if the department later determines that the service was not properly authorized or did not meet the EPA criteria. Refer to WAC 388-502-0100 (1)(c).
Rules
388-501,388-502,388-501-0169,