August 2025 Provider News
Date: 08/29/25
In this issue:
- General Updates - Autism Center for Excellence Certification and Training, HCA SERI updates, Evolent updates
- Quality - SUD Organizational Development Assessment, Annual Wellness Visits, HEDIS MY25 Volume 2
- Clinical & Payment Policies and Prior Authorization Updates - Current and upcoming policy updates
- Wellcare - Medical Clinical Policy Updates
- Training/Education - Sexual Health in Foster Care, Supporting LGBTQIA+ Youth in Foster Care, Suicide Prevention, Trauma Informed Care, Secondary Trauma & Self Care
- Pharmacy Updates - October 1, 2025 Preferred Drug List Changes
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General Updates
Autism Center for Excellence Certification and Training
CENTER OF EXCELLENCE (COE) certification allows eligible providers to diagnose autism spectrum disorder for pediatric patients with Washington State Medicaid insurance.
Live ZOOM Training: Friday, Oct 3, 2025, 8:30-4:30 pm
Eligible COE providers: MD, DO, ARNP, ND and PA-C.
Note: Neurologists, psychiatrists, licensed psychologists and developmental behavioral pediatricians are recognized as COEs without attending the training.
SLPs, OTs, mental health clinicians, care coordinators, school personnel, administrators and other partners collaborating in the evaluation or follow up care for autistic children and youth are welcome.
Presenters:
- Gary Stobbe, MD: Neurologist, Director, UW Medicine Adult Autism Clinic
- Jim Mancini, MS, CCC-SLP: Speech-Language Pathologist, University of WA, Director of WA INCLUDE and Project ECHO WA
- Jen Gerdts, PhD: Psychologist
- And additional multi-disciplinary experts
The free COE training focuses on current research and thinking regarding the evaluation, treatment and continuing care for autistic children and youth and their families including:
- Getting support from your administration
- Screening, evaluation and diagnosis
- Differential diagnosis and co-occurring diagnoses
- Diagnostic evaluation models
- Applied Behavioral Analysis (ABA) and other Interventions
- Documentation, billing codes and orders
- Lived experience perspectives from autistic and family advocates
- Advice from current community COE clinicians
- Resources for families
- ECHO Autism Washington and other follow up support
- Q & A and connect with regional partners
Please register no later than Monday of the training week you want to attend.
Email for information: autismcoe@uw.edu
HCA SERI updates
The place of service language in the Current SERI notes section of IRT is no longer applicable and will be removed in the SERI October 1, 2025 publication. Please review the latest updates from the HCA at the link below.
Service Encounter Reporting Instructions (SERI) version 2025.2 (PDF)
Evolent
Coordinated Care has partnered with Evolent to implement a new Interventional Cardiovascular prior authorization program. This program is intended to help providers effectively deliver quality patient care using clinical criteria based on nationally recognized guidelines to promote evidence-based practices.
Effective January 1, 2026, select interventional cardiovascular services will require prior authorization through Evolent prior to being rendered in an outpatient or inpatient* (*professional component of elective services only) setting.
The Evolent interventional cardiovascular program will apply to all provider specialties for the following non-emergent procedures for Coordinated Care Medicaid and Exchange members aged 21 years and older.
Cardiac catheterization and intervention
Electrophysiology
Vascular radiology and intervention
Cardiac surgery
Vascular surgery
Prior authorization requests for these services can be submitted to Evolent:
- Via the Evolent portal, select RadMD.
- Via telephone (Monday - Friday from 5:00 a.m. to 5:00 p.m. PST):
- Exchange: 1-800-424-4918
- Medicaid: 1-800-727-8627
Evolent offers providers the ability to:
- Obtain real-time approvals when selecting evidence-based treatments.
- Upload supporting clinical documentation directly to prior authorization requests.
- View all submitted requests.
- Specialty matched peer-to-peer reviews when discussing treatment options.
- Dedicated Evolent Provider Engagement Managers to address any issues or questions.
Approvals issued before January 1, 2026, are effective until the authorization end date. Upon expiration, authorization requests must be submitted to Evolent. For services/treatment that did not require an authorization prior to January 1, 2026, an authorization may be required from Evolent for service/treatment dates on and after January 1, 2026.
Evolent invites all cardiology clinicians to participate in our Clinician Engagement Program as we work to align our current key initiatives focused on heart failure, coronary artery disease (CAD), and peripheral artery disease (PAD). Your expertise and insights are vital to ensure our efforts are clinically relevant, patient-centered, and impactful. Through collaborative discussions and shared feedback, we aim to strengthen care pathways, improve patient outcomes, and drive innovation in cardiovascular health. We look forward to your engagement and partnership in shaping the future of care in these critical areas. Please contact Jason Astrin, Evolent’s Sr. Director, National Provider Engagement, at jastrin@evolent.com if your team is interested in this opportunity and we will connect on next steps.
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Quality
Medicaid Quality
The Health Care Authority (HCA), in partnership with UW Behavioral Health Institute at Harborview (BHI) and Principle Allies, developed the SUD Organizational Development Assessment (SODA) to advance quality substance use disorder (SUD) treatment across the state.
About the SODA
Created in 2023 and piloted in 2024, the SODA addresses findings that SUD providers struggle to adopt new curriculum and training due to various organizational barriers. Examples of these barriers include challenges with recruitment and retention, an inability to capture reimbursement for services rendered due to credentialing and contracting, and system service gaps that distract staff attention from clinical quality.. Universally, stakeholders and pilot participants found the SODA to be a meaningful, accurate, and useful tool to identify and plan quality initiatives.
Purpose of the SODA
The SODA assesses barriers to and facilitators of success, and it informs a tailored strategy to address training, staffing, and quality improvement efforts that focus on the unique needs of the organization and the individuals they serve. The self-administered assessment is intended to be an internal learning and planning tool. All information collected during this process should be kept confidential within the organization.
Learn more about the SODA and take the organizational assessment
Wellcare Quality
Annual Wellness Visits: Annual Preventative Wellness Visits (APV) are an opportunity to close clinical HEDIS measure gaps, establish or strengthen your Provider/Patient rapport and most importantly provide quality health care including early detection to save lives. The AWV helps develop or update a Personalized Prevention Plan (PPP) and perform a Health Risk Assessment (HRA).
Resources for Annual Wellness Visits: helpful resource tools for the AWV can be found here.
CMS website Medicare Learning Network documents 12 defined components of the First Annual Wellness Visit and subsequent Annual Wellness Visits having 11 components. Preparing eligible Patients for the AWV can include encouraging them to bring to their appointment at a minimum:
- Medical records, including immunization records
- Detailed family health history
- Full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
- Full list of current providers and suppliers involved in their care, including community-based providers (for example, personal care, adult day care, and home-delivered meals), and behavioral health specialists.
HEDIS MY25 Volume 2
The NCQA has provided new guidance as part of the HEDIS MY25 Volume 2 Technical Update that were released March 31, 2025. The following table outlines the measures that have been updated by the NCQA, and the respective Wellcare provider materials on which the original measures were originally included. For the most updated HEDIS measurements and standards, visit www.ncqa.org.
Measure | Document | Change |
(AMR) Asthma Medication Ratio | Quick Reference Guide HEDIS MY 2025 | Remove “Albuterol budesonide” prescription form Ashma Relieve medication grid |
(BCS-E) Breast Cancer Screening | HEDIS Adult Pocket Guid:2025 measurement year
| Change “(Female Age 50-74) to “(Members Age 40-74) |
Quick Reference Guide HEDIS MY 2025 | Change “Measure evaluates the percentage of members 50 to 74 years of age…” to “Measure evaluates the percentage of members 40 to 74 years of age …” | |
(CBP) Controlling High Blood Pressure | HEDIS Adult Pocket Guide: 2025 Measurement year | Remove “Telephone Visits” Best practices |
(EED) Eye Exam for Patients with Diabetes | HEDIS Adult Pocket Guide: 2025 Measurement Year | Add the following to Best Practice: “All eye exams must have result” |
Quick Reference Guide HEDIS MY 2025 | Ass the following to Codes” Autonomous Eye Exam:92229” | |
(KED) Kidney Health Evaluation for Patients with DM | HEDIS Adult Pocket Guide: 2025 Measurement Year | Change “EGR” to “eGFR” |
(SNS-E) Social Needs Screening and Intervention | Quick Reference Guide HEDIS MY 2025 | For the “Childre’s Health Watch Housing Stability Vital Signs™" line, change the “Positive Finding LOINC Codes >3” to “Positive Finding LOINC Codes ≤ 2"
|
(SPC) Statin Therapy for Patients with Cardiovascular Disease | Quick Reference Guide HEDIS MY 2025 | Change "Lovastatin 40 mg" to "Lovastatin 40-60 mg" |
(TRC) Transitions of Care | Quick Reference Guide HEDIS MY 2025 | Change “For this measure, medication reconciliation may be conducted be prescribing practitioners, clinical pharmacist, physician assistant, or registered nurse”. To “For this measure, medication reconciliation must be conducted be a prescribing practitioners, clinical pharmacists, physician assistant, or registered nurse.” |
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Clinical & Payment Policies and Prior Authorization Updates
Clinical Policy Updates
The following vision policies have been through annual review. You will find the policies on the Centene Vision Services/Envolve Website. A link is available from our Prior Authorization pages.
CP.VP.06 | Medically Necessary Optical Hardware |
CP.VP.13 | Preventive (Routine) Eye Exam |
CP.VP.14 | Scanning Computerized Ophthalmic Diagnostic Imaging |
CP.VP.26 | Extended Ophthalmoscopy |
CP.VP.28 | Fluorescein Angiography |
CP.VP.29 | Fundus Photography |
CP.VP.31 | Gonioscopy |
CP.VP.43 | External Ocular Photography |
CP.VP.63 | Visual Field Testing |
The following pain management and musculoskeletal polies have been through annual review. You will find the policies on the Evolent Website (RadMD). A link is available from our Prior Authorization pages.
ECG_1750 | Evolent - Epidural Spine Injections |
ECG_1753 | Evolent - Paravertebral Facet Point Injections or Blocks |
ECG_1754 | Evolent - Paravertebral Facet Joint Denervation (Radiofrequency Neurolysis) |
ECG_1766 | Evolent - Lumbar Spine Surgery |
ECG_1765 | Evolent - Lumbar Artificial Disc Replacement |
ECG_1756 | Evolent - Sacroiliac Joint Injections |
ECG_1759 | Evolent - Cervical Spine Surgery |
ECG_1761 | Evolent - Hip Arthroplasty |
ECG_1762 | Evolent - Hip Arthroscopy |
ECG_1763 | Evolent - Knee Arthroplasty |
ECG_1764 | Evolent - Knee Arthroscopy |
ECG_1769 | Evolent - Shoulder Arthroplasty |
ECG_1770 | Evolent - Shoulder Arthroscopy |
ECG_1758 | Evolent - Sympathetic Nerve Blocks |
ECG_1757 | Evolent - Spinal Cord Stimulation |
ECG_1767 | Evolent - Sacroiliac Joint Fusion |
ECG_1751 | Evolent - Epidural Spine Injections & Single Injection Trials for Intrathecal Pumps |
EPOS_1755 | Evolent - Place of Service for Interventional Pain Management |
EPOS_1768 | Evolent - Place of Service for Joint Surgery |
The following policies were updated as part of our regular monthly review in July. The policy changes are effective September 1, 2025. You will find the policies, including a description of the revisions, posted on the policy site.
Policy Number | Policy Title | Line of Business |
WA.CP.BH.529 | CBHS - Supportive Supervision | Apple Health |
CP.MP.94 | Clinical Trials | Apple Health & Ambetter |
CP.MP.54 | Hospice Services | Ambetter |
CP.MP.180 | Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea | Ambetter |
CP.MP.81 | NICU Discharge Guidelines | Apple Health & Ambetter |
CP.MP.82 | NICU Apnea Bradycardia Guidelines | Apple Health & Ambetter |
CP.MP.85 | Neonatal Sepsis Management | Apple Health & Ambetter |
CP.MP.86 | Neonatal Abstinence Syndrome Guidelines | Apple Health & Ambetter |
The following policies were updated as part of our regular monthly review in July. The policy changes are effective December 1, 2025. You will find the policies, including a description of the revisions, posted on the policy site.
Policy Number | Policy Title | Line of Business |
WA.CP.MP.54 | Hospice Services | Apple Health |
CP.MP.49 | Physical, Occupational and Speech Therapy Services | Apple Health & Ambetter |
WA.CP.MP.185 | Skin and Soft Tissue Substitutes | Apple Health |
CP.MP.185 | Skin and Soft Tissue Substitutes for Chronic Wounds | Ambetter |
The following policies were previously announced as revised effective on the date noted. You will find the policies posted on the policy site.
Policy Number | Policy Title | Effective Date | Line of Business |
CP.BH.500 | Behavioral Health Treatment Documentation Requirements | 9/1/25 | Apple Health |
HIM.CP.BH.500 | Behavioral Health Treatment Documentation Requirements | 9/1/25 | Ambetter |
WA.CP.MP.513 | Cardiac Stents | 9/1/25 | Apple Health |
WA.CP.MP.502 | Cochlear Implants | 9/1/25 | Apple Health |
CP.MP.50 | Drugs of Abuse: Definitive Testing | 9/1/25 | Ambetter |
WA.CP.MP.505 | Microprocessor-Controlled Lower Limb Prosthetics | 9/1/25 | Apple Health |
CP.MP.147 | Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention | 9/1/25 | Ambetter |
WA.CP.MP.185 | Skin Substitutes | 9/1/25 | Apple Health |
CP.MP.185 | Skin Substitutes for Chronic Wounds | 9/1/25 | Ambetter |
CP.MP.247 | Transplant Service Documentation Requirements | 9/1/25 | Apple Health & Ambetter |
CP.MP.132 | Heart-Lung Transplant | 10/1/25 | Apple Health & Ambetter |
CP.MP.58 | Intestinal and Multivisceral Transplant | 10/1/25 | Apple Health & Ambetter |
CP.MP.87 | Therapeutic Utilization of Inhaled Nitric Oxide | 10/1/25 | Apple Health & Ambetter |
CP.BH.200 | Transcranial Magnetic Stimulation (TMS) for TRMD | 10/1/25 | Ambetter |
CP.MP.249 | Allogeneic Hematopoietic Progenitor Cell Therapy | 11/1/25 | Apple Health & Ambetter |
CP.MP.137 | Fecal Incontinence Treatments | 11/1/25 | Apple Health & Ambetter |
CP.MP.51 | Reduction Mammoplasty and Gynecomastia Surgery | 11/1/25 | Apple Health & Ambetter |
CP.MP.127 | Total Artificial Heart | 11/1/25 | Apple Health & Ambetter |
The following new policies were previously announced effective on the dates noted. You will find the policies posted on the policy site.
Policy Number | Policy Title | Effective Date | Line of Business |
WA.CP.MP.522 | Varicose Vein Treatment | 10/1/25 | Ambetter |
WA.CP.MP.12 | Vagus Nerve Stimulation | 10/1/25 | Ambetter |
The following policies were previously announced as being archived on the dates noted.
Policy Number | Policy Title | Effective Date | Line of Business |
WA.CP.MP.50 | Drugs of Abuse: Definitive Testing | 8/31/25 | Apple Health |
CP.MP.146 | Sclerotherapy for Varicose Veins | 9/31/25 | Ambetter |
Prior Authorization Updates
The following skin substitutes will require prior authorization for Apple Health members effective September 1, 2025:
Code | Description |
C9363 | Skin substitute (Integra Meshed Bilayer Wound Matrix), per sq cm |
Q4100 | Skin substitute, not otherwise specified |
Q4103 | Oasis burn matrix, per sq cm |
Q4108 | Integra matrix, per sq cm |
Q4122 | DermACELL, Dermacell AWM or DermACELL AWM Porous, per sq cm |
Q4123 | AlloSkin RT, per sq cm |
Q4126 | MemoDerm, DermaSpan, TranZgraft or Integuply, per sq cm |
Q4127 | Talymed, per sq cm |
Q4134 | Hmatrix, per sq cm |
Q4135 | Mediskin, per sq cm |
Q4136 | E Z Derm, per sq cm |
Q4138 | BioDFence DryFlex, per sq cm |
Q4140 | BioDFence, per sq cm |
Q4143 | Repriza, per sq cm |
Q4147 | Architect, Architect PX, or Architect FX, extracellular matrix, per sq cm |
Q4149 | Excellagen, 0.1 cc |
Q4150 | AlloWrap DS or dry, per sq cm |
Q4153 | Dermavest and Plurivest, per sq cm |
Q4157 | Revitalon, per sq cm |
Q4161 | Bio-connekt wound matrix, per sq cm |
Q4162 | WoundEx Flow, BioSkin Flow, 0.5 cc |
Q4163 | Woundex, bioskin, per sq cm |
Q4164 | Helicoll, per sq cm |
Q4165 | Keramatrix or Kerasorb, per sq cm |
Q4167 | Truskin, per sq cm |
Q4168 | AmnioBand, 1 mg |
Q4169 | Artacent wound, per sq cm |
Q4173 | Palingen or Palingen Xplus, per sq cm |
Q4174 | PalinGen or ProMatrX, 0.36 mg per 0.25 cc |
Q4176 | Neopatch or therion, per sq cm |
Q4177 | FlowerAmnioFlo, 0.1 cc |
Q4179 | FlowerDerm, per sq cm |
Q4180 | Revita, per sq cm |
Q4181 | Amnio Wound, per sq cm |
Q4182 | Transcyte, per sq cm |
Q4183 | Surgigraft, per sq cm |
Q4184 | Cellesta or Cellesta Duo, per sq cm |
Q4190 | Artacent AC, per sq cm |
Q4191 | Restorigin, per sq cm |
Q4193 | Coll-e-Derm, per sq cm |
Q4194 | Novachor, per sq cm |
Q4198 | Genesis Amniotic Membrane, per sq cm |
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Wellcare
Medical Clinical Policy Updates
View the Wellcare website to see upcoming clinical policy updates that will go into effect November 1st.
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Training/Education
Sexual Health in Foster Care examines reproductive and sexual health in relationship to the foster care system. Foster youth often have higher rates of risky sexual behavior, higher rates of negative sexual outcomes, higher rates of sexual exploitation, and become sexually active earlier than their peers. This training will help participants better understand the sexual health needs of foster youth and how they can help meet these needs. Tuesday Sept 2 12p – 1:30p Register.
Supporting LGBTQIA+ Youth in Foster Care This curriculum was developed through Amara with input from Coordinated Care and guidance from many community organizations. This training is for caregivers and professionals who work in the child welfare setting. Tuesday Sept 2 1:30p – 3p Register.
Suicide Prevention Provides an overview of the topic of suicide, signs and symptoms, and how caregivers should respond in times of crisis. The training will dive into the rates of youth suicide, risk factors, and proactive steps to take for prevention. Wednesday Sept 3 01:30p Register.
Suicide Prevention: Provides an overview of the topic of suicide, signs and symptoms in youth, and how professionals and caregivers should respond in times of crisis. The training will dive into the rates of youth suicide, risk factors, and proactive steps to take for prevention. Will include a discussion on self-harm and social media. This training has many resources to utilize, as well as being useful for concerns of suicidal ideation in adults as well. Thursday Sep 18, 2025 12:01 – 02:00 PM Register.
Trauma Informed Care: Connections & Healing: Children (like adults) often define themselves through their connections. If they have been moved often, pulled from those they are connected and attached to, is it any wonder they feel and act fragmented from their lives? This in turn potentially opens the door for further trauma and disconnection. This Trauma Informed training discusses ways for caregivers and professionals to help a child develop connections, practical tips on communicating about trauma and help the child build a strength-based understanding of their personal story. Training developed by National Child Traumatic Stress Network (NCTSN) Tuesday Sep 23, 2025 01:00 -02:00 PM Register.
Secondary Trauma & Self Care
Working with youth who have experienced trauma can be difficult, draining, exhausting, and frustrating. This training will help professionals to understand the differences between Secondary Traumatic Stress, Compassion fatigue and Vicarious trauma. Participants will also be able to recognize warning signs and personal triggers, as well as understand why self-care is important and gather ideas for a personal self-care plan: Tuesday Sep 30, 2025 01:00-03:00 PM Register.
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Pharmacy Updates
October 1, 2025 Preferred Drug List Changes
Effective October 1, 2025, the drugs listed below will be non-preferred or will require a prior authorization (PA). Impacted members will be notified prior to this change.
Drug Class | Drug Name | Preferred Alternative(s) |
ANTIHYPERLIPIDEMICS: FIBRIC ACID DERIVATIVES | Fenofibrate 40 MG and 120 MG Tablet |
|
GENITOURINARY AGENTS: OVERACTIVE BLADDER AGENTS | Fesoterodine Fumarate 4 MG and 8 MG Extended Release 24 HR Tablet |
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ANTIBIOTICS: GLYCOPEPTIDES - ORAL | Firvanq HCL for Oral Solution 25 MG/ML (Base Equivalent) |
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ANTIDIABETICS: SGLT2 INHIBITORS | Invokamet 50-500 MG, 50-1000 MG, 150-500 MG, & 150-1000 MG HCL Tablet |
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ANTIDIABETICS: SGLT2 INHIBITORS | Invokana 100 MG and 300 MG Tablet |
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GASTROINTESTINAL AGENTS: INFLAMMATORY BOWEL AGENTS | Mesalamine 400 MG Delayed Release Capsule |
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DERMATOLOGICS: ANTISEBORRHEIC PRODUCTS | Sulfacetamide Sodium (Cleansing Gel) 10% |
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DERMATOLOGICS: ACNE PRODUCTS - TOPICAL | Tazarotene (Acne) Foam 0.1%
|
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GENITOURINARY AGENTS: OVERACTIVE BLADDER AGENTS | Tolterodine Tartrate 2 MG and 4 MG Capsule Sustained Release 24 HR |
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DERMATOLOGICS: ACNE PRODUCTS - TOPICAL | Tretinoin Gel 0.05% |
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GASTROINTESTINAL AGENTS: LIVE FECAL MICROBIOTA | Vowst (Fecal Microbiota Spores, Live-Brpk) Capsules | Prior Authorization (PA Required) |