September 2026 Provider News
Date: 09/30/26
In this issue:
- General Updates - Coordinated Care of WA Ophthalmology Provider Transition, Ambetter H codes updates 2027, 2027 Obstetric Billing codes changes, Provider revalidation, Critical Access Hospital Type of Bill code, Payspan Migration Zelis, HR.1 Impact and Resources, Coverage and Billing Changes for Certain Services for Members Age 18 and Younger
- Quality - Low Back Pain, Eye Exams for Diabetic patients, Weight assessments, Well child visits, 2026 Preferred Glucose Meters and Test Strips
- Tribal - IHCP Resources, Webinar Series for Tribal Communities
- Clinical & Payment Policies and Prior Authorization Updates - Policy updates
- Pharmacy Updates - Medical Oncology Update, Pharmacy Clinical Policy Updates, Gender Affirming Care: Non-Contracted Effective 10/13/2026 for members 18 years of age and younger
- Wellcare - Wellcare portal security updates
- Apple Health Core Connections - Supporting Providers through Care Coordination
- Training/Education - ACES, Culture Care & Connections, AHCC, Joint MCO Live Training Sessions, Neurodivergent Provider Support Network Virtual Gathering
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General Updates
Coordinated Care of WA Ophthalmology Provider Transition
Effective for service dates beginning January 1, 2027, Coordinated Care of WA will assume the management of medical eye care services delivered by ophthalmologists for all Coordinated Care of WA Medicaid and Ambetter (Marketplace) members.
Centene Vision will continue to manage routine eye care services and full-scope of licensure optometric services for Coordinated Care of WA.
Coordinated Care of WA will be responsible for the following functions for ophthalmologists providing medical eye care services beginning January 1, 2027, to include:
- Contracting, Credentialing
- Claim Processing, Claim Appeals
- Provider Services
- Provider Relations/Account Management
- Provider Education and Resource Materials (Provider Manual, Training)
- Provider Web Portal
- Prior Authorization, Retrospective Utilization Review, Medical Necessity Appeals
- Provider Complaints
For your convenience, Coordinated Care of WA and Centene Vision have included a Resource Guide below, that details contact and other information for all applicable functions for both medical eye care services and routine vision services for ophthalmology providers. If you have questions or concerns regarding this transition, please contact Coordinated Care of WA’s Provider Services Department at 877.644.4613 and reference this communication.
| COORDINATED CARE MEDICAL EYE CARE Ophthalmology | CENTENE VISION |
Provider Enrollment (Contracting & Credentialing) | To contract with Coordinated Care of WA for all ophthalmology medical eye care services, visit Coordinated Care of WA’s website here and complete a request to join our network. | To contract with Centene Vision for routine eye and optometry medical services, please visit Centene Vision’s website and submit a Network Management inquiry form. |
Claims | ||
Electronic Claims Payor ID | 68069 | 56190 |
Claims Submission
| Submit all ophthalmology claims to Coordinated Care of WA: Electronically (EDI): Use Payor ID# 68069 Online via: Coordinated Care of WA Secure Provider Portal Via email: EDIBA@centene.com Paper claims: Coordinated Care Health | Submit all routine vision, optometry medical services, and hardware claims to Centene Vision: Electronically (EDI): Use Payor ID# 56190 Online via Eye Health Manager Paper claims: Centene Vision |
Provider Services | ||
| Claims Inquiries | Coordinated Care of WA (Medicaid) Provider Services: 877.644.4613 8AM – 5PM PT | Centene Vision Services claim inquiries: 855.745.5527 |
| Claims Correction | Corrected claims must be received within 24 months from the date of service. Corrected claims can be submitted by mail to: Coordinated Care of WA | Centene Vision accepts corrected claims. Corrected claims must include all services rendered on the date of service. Include the appropriate Resubmission Code and original claim number in Item 22 of the CMS 1500 claim form or equivalent electronic field or indicate CORRECTED CLAIM and the original claim number on web. Find more information here. |
| Claim Disputes | Providers may submit a claim dispute by mail to: Coordinated Care of WA | Complete this form (PDF) for claim appeals/reconsiderations. |
Provider Relations/Account Management | Provider Services for Coordinated Care of WA can be reached at 877.644.4613. | Providers of routine eye and optometry medical services who have participation or credentialing inquiries can contact Centene Vision at |
Provider Education & Resource Materials | Coordinated Care of WA’s online provider resources can be found here. | Visit here for Centene Vision’s provider forms and resources. |
Prior Authorization | For Medicaid claims, use Coordinated Care Medicaid Pre-Auth Check Tool For Ambetter claims, use the Coordinated Care Ambetter Pre-Auth Check Tool | Optometry medical services administered by Centene Vision are subject to Centene Vision’s policies and authorization requirements. Detailed instructions for submitting prior authorization requests can be found on our website at Provider Forms (centenevision.com/forms). Click on Online Forms and Prior Authorization Request Forms. Prior authorization requests can be submitted via: Fax: 877.865.1077 For more information, please call Centene Vision Utilization Management at 800.465.6972. |
| Provider Disputes | Disputes related to ophthalmology claims should be filed within 24 months from the date of service and be mailed to: Coordinated Care of WA | For complaints related to routine services by an optometrist: Email: visiongrievances@centene.com Or mail: Centene Vision Services |
Ambetter from Coordinated Care Corporation Billing Code Update for various HCPC H Codes
Effective 01/01/2027
The H codes outlined below will no longer be covered by Ambetter from Coordinated Care beginning on 01/01/2027.
H0003 | H0004 | H0005 | H0007 | H0008 | H0009 |
H0010 | H0011 | H0012 | H0013 | H0014 | H0016 |
H0021 | H0024 | H0026 | H0027 | H0028 | H0029 |
H0030 | H0034 | H0037 | H0039 | H0040 | H0041 |
H0042 | H0043 | H0044 | H0045 | H0046 | H0047 |
H1011 | H2001 | H2010 | H2011 | H2012 | H2013 |
H2015 | H2016 | H2018 | H2021 | H2022 | H2028 |
H2029 | H2030 | H2031 | H2032 | H2033 |
|
The H code below will be covered by Ambetter from Coordinated Care beginning on 01/01/2027.
- HCPC Code H0006
If you have questions about this bulletin or other provider resources, please contact your Provider Relations Representative.
OB Billing code changes 01/01/2027
Obstetric billing will change on 1/1/2027, with deletion of global codes in favor of itemized services.
A project team within HCA is actively working toward implementation of the changes, which represent a seismic shift for both providers and payers. HCA understands the importance of providing the plans 90-day advance notice about policy updates and strives to meet this benchmark. However, the tight, inflexible timeline presented by the obstetric code changes means HCA will be unable to share a comprehensive clinical policy by 10/1/2026. The policy information available as of that date would be incomplete, potentially erroneous, and require additional notices to the plans. HCA leadership has instead directed the obstetric code project team to delay notification until internal policy development is finalized. HCA intends to send the plans a complete obstetric policy at the end of November or beginning of December. HCA is hopeful that system updates for plans to accommodate the code changes will be straightforward and can be accomplished in a short turnaround time.
Status summary for HCA’s obstetric code project:
- HCA presented project information at the MCO Operations meeting on 5/8/2026 and the MCO Medical Director’s meeting on 6/5/2026.
- Rulemaking to update Washington Administrative Code is in process and is expected to be complete by 1/1/2027.
- Language updates for the managed care contracts are in process, with expected completion by 1/1/2027.
- HCA hosted a public webinar on 6/3/2026. The slides and FAQ are publicly available on Pregnancy services: clinical care
- The FAQ is regularly updated as new questions come to HCA.
- CMS proposed rules impacting the new obstetric codes, with the public comment period open until 9/14/2026. There is ongoing uncertainty about how CMS actions will affect obstetric billing and the valuation of the new codes. CMS final rule is anticipated in November.
- HCA plans to host an additional webinar prior to the 1/1/27 implementation. Our intent is to present the complete obstetric policy during that session. However, scheduling remains challenging, as HCA must select a webinar date far enough in advance to support stakeholder and partner participation, yet after the clinical policy information is finalized.
Provider Revalidation
HCA and DSHS will contact providers to revalidate
The Centers for Medicare & Medicaid Services (CMS) directed the Health Care Authority (HCA) and the Department of Social and Health Services (DSHS) to complete revalidations of all Apple Health (Medicaid) providers by June 5, 2028.
HCA and DSHS will contact providers who must complete an off-cycle revalidation.
See the HCA and DSHS off-cycle provider revalidation project webpage for updates.
What is provider revalidation?
Revalidation is a required process every five years to confirm that Apple Health provider enrollment information and credentials are accurate and meet state and federal regulations. DSHS revalidation occurs when a Medicaid contract is renewed.
What is off-cycle revalidation?
Off-cycle revalidation happens outside the standard five-year revalidation schedule or outside of the DSHS contract renewal.
Review the frequently asked questions (FAQ) to learn about the process and what to expect.
Visit the off-cylce provider revalidation FAQ.
Contact:
HCA Provider enrollment
Phone: 1-800-562-3022, ext. 16137
Phones are open: Tuesdays and Thursdays from 7:30 a.m. to 4:30 p.m. (Closed from noon to 1 p.m.)
Phones are closed: Mondays, Wednesdays, and Fridays.
DSHS
Critical Access Hospital Type of Bill Code Requirements
Ambetter is providing information regarding the billing requirements for any facility contracted with Ambetter as a Critical Access Hospital (CAH).
All facilities contracted as Critical Access Hospitals must submit claims using the appropriate Type of Bill (TOB) based on the services rendered. Claims submitted with an incorrect TOB will be denied and require correction and resubmission. The allowable CAH bill types are 11X, 85X, 14X, and 18X, based on the applicable service provided.
Please submit claims using the following Type of Bill designations.
Service Type | Appropriate Type of Bill |
Inpatient Hospital Services | 11X |
Outpatient Hospital Services | 85X |
Laboratory Services | 14X |
Swing Bed Services | 18X |
Other services | As applicable per CMS and contractual billing requirements. |
Ambetter encourages CAH providers to review their claim submission practices and make any necessary system updates to avoid disruptions in claims adjudication.
For additional information regarding this claim submission requirement, please review the applicable Ambetter Provider Manual.
If you have questions, contact your Ambetter Provider Relations Representative or Provider Services team for assistance.
Payspan Migration Zelis
With Zelis’ acquisition of Payspan we’re pleased to announce that Coordinated Care is transitioning to Zelis for both claims and non-claims payments.
The transition to the new payment platform will occur in phases, with Medicare, Medicaid, Behavioral Health, and Ambetter programs moving throughout November, December, and into early 2027. To ensure uninterrupted access to electronic payments and remittance information across all participating lines of business, we encourage you to enroll with now. Once enrolled, any additional eligible lines of business that move to the new platform will automatically be included, and no further action will be required.
How This Impacts You
- In partnering with Zelis, we’re excited to offer you more efficiency and choice in how you receive claims payments and remittance data. Your options include:
- ZAPP Edge - direct settlement into the provider’s bank account via ACH plus data and performance insights from 550+ payers in a single portal
- Virtual Card (VCC) - one-time use virtual card
- ePayment Center - cost-free standard EFT/ERA solution that delivers payment via ACH
- Paper Check - free paper check delivery via USPS (default payment method)
- Through this new partnership, you’ll gain access to Zelis’ premium payer payments experience, ZAPP Edge, which offers payments, data, and financial performance insights from 550+ payers in a single portal.
What You Need to Know
- If you’re already enrolled with Zelis payments on ZAPP Edge to receive claim payments via ACH or VCC, no action is needed. Payments will be routed according to your current preferences under your Zelis agreement.
- If you’re not enrolled with Zelis payments on ZAPP Edge, to avoid any disruption to your payment preferences, act now and select your preferred electronic payment method using the contact information below:
- ZAPP Edge or VCC: call a Zelis Advisor at 877-828-8770
- CenteneClaims Payment ePayment Center (free standard EFT/ERA)
- If you are not already enrolled with Zelis for VCC or ZAPP Edge and do not enroll in the free ePayment Center, payments will be sent via paper check through the USPS.
- If you receive non-claims payments, you may have additional registration steps to complete. Registration for non-claims payments can be completed by navigating here.
More information on this process will be provided closer to the transition period.
Questions
Coordinated Care and Zelis are committed to supporting you throughout this transition. If you have questions about your payment options, need additional help making your selection, or want to change your payment method please use the contact information below.
- ePayment Center: 855-774-4392 or email: help@epayment.center
- ZAPP Edge or VCC: Contact Zelis Client Services at 877-828-8770
HR.1 Impact and Resources
Please visit the HCA links below for further information on H.R. 1
- Implementation for legislators, partners, and other stakeholders
- Work requirements coming to Apple Health (Medicaid)
- Webinars – see the stakeholder webinars in the resource section on the below link for a list of upcoming Webinars
Important Update: Coverage and Billing Changes for Certain Services for Members Age 18 and Younger
A new federal regulation prohibits states from using federal Medicaid funds to pay for certain gender-affirming care (GAC) for minors, referred to as “sex-rejecting procedures.” This regulation goes into effect on October 13, 2026. See 91 Fed. Reg. 52406 (August 13, 2026) (adding new Subpart N to 42 CFR Part 441) -16508 (91 FR 52406). Accordingly, effective October 13, 2026, the Health Care Authority (HCA) will use state funds to pay for these services.
What is changing?
Beginning October 13, 2026, certain services provided to members age 18 and younger will transition from Managed Care Organization (MCO) reimbursement to Fee-for-Service (FFS) reimbursement.
Affected services may include:
- Certain inpatient procedures
- Certain outpatient procedures
- Physician-administered medications
- Certain medications dispensed by pharmacies
What providers need to know
- These services will continue to be covered for eligible members.
- Providers should expect the payer for affected services to change from the member's MCO to Fee-for-Service (FFS).
- HCA is updating ProviderOne and pharmacy systems to support FFS reimbursement.
- Additional billing guidance, coding information, and implementation details will be shared by HCA as they become available.
- HCA and health plans will work together during implementation to help ensure claims are processed appropriately.
Member Impact
There is no action required from members, and no disruption in access to covered services is expected. Members should not notice a change other than how these services are funded and reimbursed.
Additional Information
HCA will provide updated billing guidance, coding requirements, and drug coverage information, including updates to Provider Billing Guides and applicable drug lists. Providers should watch for future communications regarding implementation and billing instructions.
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Quality.
Low Back Pain
The percentage of persons 18–75 years of age with a principal diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.
Clinical guidelines for treating patients with acute low back pain strongly recommend against the use of imaging in the absence of “red flags” (i.e., indications of a serious underlying pathology such as a fracture or tumor)4. Routine imaging is problematic because it is not associated with improved outcomes and exposes patients to harms such as radiation exposure and unnecessary treatment5. Red flag conditions include history of cancer, osteoporosis and IV drug use.
Use of Imaging Studies for Low Back Pain (LBP) - NCQA
Eye Exam for Patients with Diabetes- HEDIS
Diabetes is the leading cause of blindness in people 18–64 years old—and there are often no obvious signs or symptoms.
Eye Exam for Patients With Diabetes (EED) - NCQA
Medicaid Quality
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)
Below are the ICD-10 codes that can be used to close the WCC care gap.
WCC Component | ICD-10 Code |
BMI <5TH percentile | Z68.51 |
BMI 5TH to <85th percentile | Z68.52 |
BMI 85th to <95th percentile | Z68.53 |
BMI > or = to 95th percentile | Z68.54 |
Nutritional Counseling | Z71.54 |
Physical Activity Counseling | Z71.82, Z02.5 |
Well-Child Visits in the First 30 Months of Life (W30)
A total of eight well-care visits is recommended from the time the child is born to the time they reach 15 months old. The visits that occur before the 15-month birthday are of particular importance because this is the period when an infant undergoes substantial changes in abilities, physical growth, motor skills, hand-eye coordination and social and emotional growth. They are foundational to preventive health care, such as evidence-based screenings and immunizations, because they promote better social, developmental and health outcomes.
Well-Child Visits in the First 30 Months of Life (W30) - NCQA
Trusted, clear, and compassionate guidance from providers is especially important now, as parents rely on them to navigate information and make science‑based decisions for their adolescents’ health. HEDIS Help – Immunizations for Adolescents (IMA-E)Coordinated Care of Washington, Inc. would like to help improve your quality scores on the Immunizations for Adolescents (IMA-E) Healthcare Effectiveness Data and Information Set (HEDIS) measure that assesses the percentage of teens 13 years old who received the following vaccines prior to their 13th birthday:
Vaccine | Routine Recommendation |
Tdap | 1 dose at age 11–12 years |
HPV (Human Pap | 2-dose series starting at age 9–14 (0, 6–12 months) |
MenACWY (Meningococcal ACWY) | 1 dose at 11–12 years |
The Washington State Department of Health in alignment with the West Coast Health Alliance continues to recommend the American Academy of Pediatrics (AAP) Recommended Child and Adolescent Immunization Schedule (PDF).
Wellcare Quality
2026 Preferred Glucose Meters and Test Strips
2026 Preferred Blood Glucose Meters and Strips | Restrictions | |
Blood Glucose Monitors |
| Quantity Limit:
|
Test Strips |
| |
*Includes Relion labeled products
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Tribal
IHCP Resources
IHCPs have access to a dedicated email inbox for inquires regarding all lines of business at Coordinated Care (Medicaid, Marketplace/Exchange, and Medicare Advantage). Please don’t hesitate to reach out to IndianHealthCareProviderAssistance@coordinatedcarehealth.com and the team monitoring the inbox will assist or connect you with the appropriate contacts to resolve your questions.
Coordinated Care Presents: 2026 Webinar Series for Tribal Communities
Coordinated Care can support Tribal members and families in accessing care by assisting with appointments, follow-up after hospital visits, and overcoming barriers like transportation or medication access – working in partnership with Tribal health programs to support whole‑person wellness.
Visit our website to learn more.
What: Session topics will include:
- Care Coordination – an overview of care coordination services and support with resolving common issues
- Recommended for:
- Tribal Providers
- Behavioral health professional (social workers, case managers)
- Community Based Organizations (CBO’s)
- Recommended for:
- Annual open enrollment- an overview of Coordinated Care’s Medicaid and Ambetter (Marketplace) plan offerings
- Recommended for:
- Tribal assisters (health benefits enrollment staff)
- Tribal providers
- Recommended for:
When: See below for dates, times, and registration information for each session.
Q4 — Thursday, October 22 11am-12pm- 2027 Annual Enrollment Period (AEP)
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Clinical & Payment Policies and Prior Authorization Updates
Clinical Policy Updates
The following policies are updated as of the listed Effective Date.
Policies are posted on the Coordinated Care of Washington Policy webpage.
New to List? | Policy # | Policy Title | Line of Business | Change Type | Effective Date |
| CP.BH.105 | Applied Behavioral Analysis Documentation Requirements | Ambetter | Revised | 10/1/2026 |
X | CP.BH.200 | Transcranial Magnetic Stimulation (TMS) for TRMD | Ambetter | Revised | 10/1/2026 |
| CP.BH.500 | Behavioral Health Treatment Documentation Requirements | Apple Health | Revised | 10/1/2026 |
X | CP.MP.109 | Panniculectomy | Apple Health, Ambetter | Revised | 10/1/2026 |
X | CP.MP.110 | Bronchial Thermoplasty | Apple Health, Ambetter | Revised | 10/1/2026 |
X | CP.MP.121 | Homocysteine Testing | Apple Health, Ambetter | Revised | 10/1/2026 |
X | CP.MP.123 | Laser Therapy for Skin Conditions | Apple Health, Ambetter | Revised | 10/1/2026 |
X | CP.MP.138 | Pediatric Heart Transplant | Apple Health, Ambetter | Revised | 10/1/2026 |
X | CP.MP.139 | Low-Frequency Ultrasound and Noncontact Normothermic Wound Therapy | Apple Health, Ambetter | Revised | 10/1/2026 |
X | CP.MP.167 | Intradiscal Steroid Injections for Pain Management | Apple Health, Ambetter | Revised | 10/1/2026 |
X | CP.MP.169 | Trigger Point Injections for Pain Management | Apple Health, Ambetter | Revised | 10/1/2026 |
| CP.MP.185 | Skin Substitutes for Chronic Wounds | Ambetter | Revised | 10/1/2026 |
X | CP.MP.203 | Diaphragmatic/Phrenic Nerve Stimulation | Apple Health, Ambetter | Revised | 10/1/2026 |
X | CP.MP.250 | Lantidra (donislecel): Allogeneic pancreatic islet cellular therapy | Apple Health, Ambetter | Revised | 10/1/2026 |
X | CP.MP.50 | Drugs of Abuse: Definitive Testing | Apple Health, Ambetter | Revised | 10/1/2026 |
| CP.MP.58 | Intestinal and Multivisceral Transplant | Apple Health, Ambetter | Revised | 10/1/2026 |
X | CP.MP.61 | IV Moderate Sedation, IV Deep Sedation and General Anesthesia for Dental Procedures | Ambetter | Revised | 10/1/2026 |
X | CP.MP.81 | NICU Discharge Guidelines | Apple Health, Ambetter | Revised | 10/1/2026 |
X | CP.MP.82 | NICU Apnea Bradycardia Guidelines | Apple Health, Ambetter | Revised | 10/1/2026 |
X | CP.MP.85 | Neonatal sepsis management | Apple Health, Ambetter | Revised | 10/1/2026 |
| HIM.CP.BH.500 | Behavioral Health Treatment Documentation Requirements | Ambetter | Revised | 10/1/2026 |
X | V2.2025 | CG Prenatal Screening | Ambetter | Revised | 10/1/2026 |
X | WA.CP.BH.200 | Transcranial Magnetic Stimulation (TMS) for TRMD | Apple Health | Revised | 10/1/2026 |
X | WA.CP.BH.529 | CBHS - Supportive Supervision | Apple Health | Revised | 10/1/2026 |
X | WA.CP.MP.12 | Vagal Nerve Stimulation | Apple Health, Ambetter | Revised | 10/1/2026 |
X | WA.CP.MP.166 | Sacroiliac Joint Interventions for Pain Management | Apple Health, Ambetter | Revised | 10/1/2026 |
X | WA.CP.MP.231 | CG Non-Invasive Prenatal Screening | Apple Health | Revised | 10/1/2026 |
X | WA.CP.MP.501 | Continuous Glucose Monitoring System | Apple Health, Ambetter | Revised | 10/1/2026 |
X | WA.CP.MP.507 | Oral Enteral Nutrition | Apple Health | Revised | 10/1/2026 |
X | WA.CP.MP.95 | Gender Affirming Procedures | Ambetter | Revised | 10/1/2026 |
| CP.MP.120 | Pediatric Liver Transplant | Apple Health, Ambetter | Revised | 11/1/2026 |
| CP.MP.129 | Fetal Surgery in Utero for Prenatally Diagnosed Malformations | Apple Health, Ambetter | Revised | 11/1/2026 |
| CP.MP.185 | Skin Substitutes for Chronic Wounds | Apple Health | Revised | 11/1/2026 |
| CP.MP.49 | Physical, Occupational and Speech Therapy Services | Apple Health, Ambetter | Revised | 11/1/2026 |
| CP.MP.54 | Hospice Services | Ambetter | Revised | 11/1/2026 |
| WA.CP.MP.248 | Sleep Apnea Diagnosis and Treatment | Apple Health | Revised | 11/1/2026 |
X | CP.BH.104 | Applied Behavior Analysis Therapy | Ambetter | Revised | 1/1/2027 |
X | CP.MP.133 | Posterior Tibial Nerve Stimulation for Voiding Dysfunction | Ambetter | Revised | 1/1/2027 |
X | CP.MP.86 | Neonatal abstinence syndrome guidelines | Apple Health, Ambetter | Revised | 1/1/2027 |
X | WA.CP.BH.528 | HRSN - Intensive Behavioral Supportive Supervision | Apple Health | Revised | 1/1/2027 |
X | WA.CP.MP.54 | Hospice Services | Apple Health | Revised | 1/1/2027 |
Prior Authorization Updates
As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, we share some important updates to our PA requirements. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.
Code change details can be found below. These changes may include:
- Removing PA requirements based on criticality of review and clinical need.
- Creating a more uniform set of prior authorization requirements across our markets and lines of businesses, including adding and changing some PA requirements, to simplify processes, reduce confusion for providers, and support future efforts to expand real-time responses to requests.
If you have questions about specific prior authorization codes or how these changes affect your practice, please reach out to your Provider Engagement representative.
Utilize our Pre-Auth Check tool for real time response to pre-authorization requirements.
Code | Service | Line of Business | Effective Date | Notes |
38208 | Transplant | Ambetter | 10/1/2026 | No PA Required |
81378, 81379, 81380, 81381, 81382, 81383, 86812, 86813, 86817 | Genetic Testing | Ambetter | 10/1/2026 | No PA Required |
S9211, S9213, S9214 | Home Visit | Ambetter | 10/1/2026 | No PA Required |
31276, 31296, 31297, 31298 | Sinus Surgery | Ambetter | 10/1/2026 | PA Required |
92526 | Oral Function Therapy | Apple Health | 10/1/2026 | Members under 21: No authorization required for all providers. Members over 21: Authorization is required after the first 6 visits per calendar year for PAR providers. Non-PAR always requires authorization. |
67904 | Eye and Ocular Adnexa | Apple Health | 10/1/2026 | No PA Required |
42820, 42825, 42830, 42835, 42836 | Tonsil and Adenoid Procedures | Apple Health | 10/1/2026 | No PA Required |
81161, 81200, 81206, 81207, 81240, 81241, 81242, 81243, 81250, 81251, 81255, 81256, 81260, 81279, 81297, 81304, 81319, 81338, 81339, 81371, 81373, 81376, 81379, 81380, 81381, 81382, 81401, 88230, 88280, 88291 | Genetic Testing | Apple Health | 10/1/2026 | No PA Required |
E2607 | Wheelchair | Apple Health | 10/1/2026 | No PA Required |
L5000, L5631, L5704, L5920, L5950 | Orthotic and Prosthetic | Apple Health | 10/1/2026 | No PA Required |
55899 | Genital Surgery Procedure | Apple Health | 10/1/2026 | PA Required |
81519 | Genetic Testing | Apple Health | 10/1/2026 | PA Required |
91299 | Gastroenterology Procedure | Apple Health | 10/1/2026 | PA Required |
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Pharmacy
Medical Oncology Update
Prior Authorization requests for the following HCPCS codes need to be verified by Evolent.
HCPCS | Generic Name | Brand Name | Medical PA | Pharmacy PA | Impact Description |
J9999 | PIVEKIMAB SUNIRINE-PVZY INJECTION | DECNUPAZ | Yes | Yes |
|
J8999 | DASATINIB ORAL | PHYRAGO | Yes | Yes |
|
J9999 | ETOPOSIDE INJECTION | AVOPEF | Yes | Yes |
|
J9999 | FLUOROURACIL INJECTION | FAVLYXA | Yes | Yes |
|
J9999 | TRABECTEDIN INJECTION | EVDI | Yes | Yes |
|
J9999 | FULVESTRANT INJECTION | CLIGAVYX | Yes | Yes |
|
J9999 | GEDATOLISIB INJECTION | REVTORPYK | Yes | Yes |
|
J9999 | SATUXIMAB-IRFC INJECTION | SARCLISA ESCENA | Yes | Yes |
|
Participating providers should submit oncology/supportive drug authorization for members through Evolent.
Pharmacy Clinical Policy Updates
The following pharmacy policies have been updated or will be retired. Updated policies will be posted to the policy site.
A summary of the revisions is available in the policy revision log at the end of the policy.
Policy Number | Policy Title | Effective Date | Line of Business | Change (Updated/Retired) |
CP.PHAR.524 | Pegcetacoplan (Empaveli, Syfovre) | 10/01/2026 | Ambetter | Updated |
CP.PHAR.565 | Asciminib (Scemblix) | 10/01/2026 | Ambetter | Updated |
CP.PHAR.582 | Lutetium Lu 177 vipivotide tetraxetan (Pluvicto) | 10/01/2026 | Ambetter | Updated |
CP.PHAR.674 | Marstacimab-hncq (Hympavzi) | 10/01/2026 | Ambetter | Updated |
CP.PHAR.720 | Nipocalimab-aahu (Imaavy) | 10/01/2026 | Ambetter | Updated |
CP.PMN.295 | Semaglutide (Wegovy) | 10/01/2026 | Ambetter | Updated |
CP.PMN.298 | Tirzepatide (Zepbound) | 10/01/2026 | Ambetter | Updated |
HIM.PA.53 | GLP-1 receptor agonists | 10/01/2026 | Ambetter | Updated |
CP.PHAR.232 | OnabotulinumtoxinA (Botox) | 10/01/2026 | Ambetter & Medicaid | Updated |
CP.PHAR.260 | Rituximab (RItuxan, Truxima, Riabni, Zimrixby, Ruxience, Rituxan Hycela) | 10/01/2026 | Ambetter & Medicaid | Updated |
CP.PHAR.568 | Inclisiran (Leqvio) | 10/01/2026 | Ambetter & Medicaid | Updated |
CP.PHAR.605 | Adagrasib (Krazati) | 10/01/2026 | Ambetter & Medicaid | Updated |
CP.PHAR.768 | Lerodalcibep-liga (Lerochol) | 10/01/2026 | Ambetter & Medicaid | Updated |
CP.PHAR.774 | Vusolimogene Oderparepvec-wtpg (Tudriqev) | 10/01/2026 | Ambetter & Medicaid | Updated |
CP.PHAR.794 | Daraxonrasib (Rasonque) | 10/01/2026 | Ambetter & Medicaid | Updated |
CP.PHAR.774 _PEPP | Vusolimogene Oderparepvec (RP1)_PEPP | 10/01/2026 | Ambetter & Medicaid | Retired |
Gender Affirming Care Drugs- Non-Contracted Effective 10/13/2026 for Members 18 Years of Age and Younger
A new federal regulation prohibits states from using federal Medicaid funds to cover certain gender-affirming care services for minors, referred to as “sex-rejecting procedures.” Effective October 13, 2026, certain drugs associated with gender-affirming care, regardless of diagnosis, for members 18 years of age or younger must be billed through fee-for-service.
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Wellcare
A New Security Update is Coming Soon
To better protect provider and member information, we’re adding an extra layer of security when you log in to the secure Wellcare. We know logging in is part of your daily workflow, and this update is designed to add security while keeping the process simple and familiar.
What to expect
- Starting soon, you will be asked to use multi-factor authentication (MFA) when logging in to the provider portal.
- After entering your username and password, you’ll confirm your login with a one-time code sent via SMS to your phone.
- Once you’re signed in, everything in the portal will work the same as it does today.
Why is this change being made
This enhancement:
- Provides an additional layer of protection for provider and member data.
- Advances a more secure, consistent provider portal experience.
What you need to know
- No action is needed today.
- When this goes live:
- Enter your username and password.
- Add your phone number.
- Enter the verification code sent to your phone.
- Enter your username and password.
- After your first login:
- Enter your username and password.
- Enter the verification code sent to your phone.
- Enter your username and password.
Key details
- Your phone number will only be used to verify your login.
- It will not be stored in any provider or member database or be used for marketing, outreach or other communications.
- If you already use Availity Essentials, you’re likely familiar with this process and can continue to access services there if preferred.
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Apple Health Core Connections
Coordinated Care is the single managed care organization to administer the Integrated Managed Care Apple Health Foster Care program in collaboration with the Washington State Health Care Authority and Washington State Department of Children, Youth and Families. Our program, Apple Health Core Connections, serves children and youth in foster care, adoption support, alumni of foster care (ages 18-26), children reunified with their parents, and youth in the Unaccompanied Refugee Minor program.
Apple Health Core Connections staff partner with caregivers, caseworkers, providers, Tribes, parents, and youth to ensure members get the care they need. Our care coordination team can support with:
- Referrals
- Plans for children/youth discharging from the ER or hospital
- Medication/pharmacy issues
- Support children/youth with multiple or complex needs
- Home Health care
- Support and education for health conditions (e.g., asthma, anxiety, diabetes)
- Accessing durable medical equipment and medical supplies
- Making connections to community resources and supports
- Suicide prevention and safety planning
- And more!
Call 1-844-354-9876, prompt “2” and ask for “Health Care Coordination” or email AHCCTeam@coordinatedcarehealth.com with the patient name, date of birth, Provider One or AHCC member number, and how we can help.
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Training/Education
Adverse Childhood Experiences (ACEs) This training explains the Adverse Childhood Experiences (ACEs) study and identifies all 10 ACEs. All childhood experiences have an impact on people as they mature. This training explores the long term effects that adverse childhood experiences have on physical and mental health. Preventative measures, resiliency, and how to address the needs of children with a high ACEs score are all discussed. Oct 5, 2026 02:00 PM – 3:30 PM Register now.
Cultural Care & Connections This training explains the importance of cultural differences when caring for a child of a different race or culture. It provides insight on how the caregiver can recognize different values, beliefs, behaviors, communication variations and potential barriers, including personal care. Additionally, this training addresses the need to keep children connected to their culture of origin. Oct 6, 2026 02:00 PM – 3:30 PM Register now.
AHCC – Coordinated Care Overview This overview provides a practical introduction to Apple Health Core Connections (AHCC) for children and youth involved in foster Care, Kinship and related programs. Participants will learn who is eligible, what medical and behavioral health benefits are covered, how ProviderOne and Coordinated Care work together, and how to access Care Coordination and a whole host of Value-Added Supports. The session also highlights resources for caregivers, caseworkers, and youth, including pharmacy, vision, behavioral health services, telehealth, and community-based programs designed to support whole-child wellbeing. Oct 8, 2026 02:00 PM – 3:30 PM Register now.
Annual Joint MCO Live Training Sessions 2026
Washington’s Managed Care Organizations (MCOs) invite you to participate in the joint 2026 Apple Health (Medicaid) & Medicare Advantage Provider Training. This collaborative event features presentations from Community Health Plan of Washington, Coordinated Care of Washington, Inc., Molina Healthcare of Washington, UnitedHealthcare Community Plan of Washington, and Wellpoint Washington.
Compliance Note: Attending one of these training sessions will successfully satisfy your annual attendance requirement under 42 CFR 38.608(a)(1)iv.
Who Should Attend: Providers and Staff
Agenda & Registration
Core Topics Covered:
- Enrollee Rights & Responsibilities
- Advanced Directives
- Fraud, Waste and Abuse
- False Claims Act
- Cultural Awareness
Where: Hosted virtually via Webinar.
When: Multiple dates are available. Please use the date-specific links below to register for your single required session.
Date | Session | Time | Registration Link |
October 27, 2026 | Session 1 | 12:00 PM | |
October 28, 2026 | Session 2 | 5:00 PM | |
October 29, 2026 | Session 3 | 1:00 PM | |
November 3, 2026 | Session 4 | 8:00 AM | |
November 4, 2026 | Session 5 | 8:00 AM | |
November 5, 2026 | Session 6 | 1:00 PM |
Following the training, you will be asked to complete a brief survey. This will confirm your participation and allow you to share your valuable feedback.
Thank you for your ongoing partnership in serving our members. We look forward to seeing you there!
Neurodivergent Provider Support Network virtual gathering
Join WA INCLUDE for a time of connection and support intended for Neurodivergent humans providing support for youth and young adults with Intellectual/Developmental Disabilities.
Starting October 6th
- 1st Tuesday @ 12:00pm
- 3rd Tuesday @ 8:00am
For more information visit this link.