Apple Health (Medicaid) Pre-Auth

For the best experience, please use the Pre-Auth tool in Chrome, Firefox, or Internet Explorer 10 and above.

DISCLAIMER: All attempts are made to provide the most current information on the Pre-Auth Needed Tool. However, this does NOT guarantee payment. Payment of claims is dependent on eligibility, covered benefits, provider contracts, correct coding and billing practices. For specific details, please refer to the provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response. All new, re-sequenced and unlisted codes (miscellaneous codes) require prior authorization, regardless of place of service.

Please refer to the Prior Authorization page for questions.

Please check the State Apple Health Guidelines for Covered Benefits. Exclusions and limitations to these benefits can also be found on the Washington State Health Care Authority site.

For services related to Gender Affirming Care, except services covered under the pharmacy benefit, please contact the Health Care Authority. For more information, visit Step-by-step guide for prior authorization | Washington State Health Care Authority.

Prior Authorization at a Glance

Prior Authorization is NOT Required

The following services do NOT require prior authorization:

Services rendered in an emergency room or urgent care center
Services rendered by a public health or welfare agency
Family planning services billed with a contraceptive management diagnosis

Prior Authorization IS Required

The following services REQUIRE prior authorization:

Services rendered by an out out-of-network provider, with the exception of emergency and urgent care services
Admission of a member to an inpatient facility
Hospice services
Anesthesia services for pain management or dental procedures.
Services rendered at home, other than DME, orthotics, prosthetics, supplies and therapeutic injections
Services rendered by a chiropractor

Prior Authorization Check

Required Field

Enter Service Code

To submit a prior authorization Login Here

Non-Covered Services

Members age 0-20: Service codes that are not covered may be requested as medically necessary under EPSDT requirements for members age 20 and under. To request these services, follow our normal Prior Authorization process using fax PA forms or our provider web portal.
Members age 21 and above: Services codes that are non-covered may be requested under the Exception to Rule (ETR) process per WAC 182-501-0160. To request we cover these services, complete an ETR form (PDF) and fax to number listed on form. For Durable Medical Equipment no Exception to the Rule Form needs to be submitted, please submit a regular Prior Authorization Form only. All ETRs should be submitted to Coordinated Care and not our delegated vendors.

Non-Contracted Drugs

Please refer to our Non-Contracted Drugs lists below to see which drugs may be covered by Fee for Service.
- Coordinated Care (Apple Health) Non-Contracted Drugs List (PDF)
- Coordinated Care (Apple Health Expansion) Non-Contracted Drugs List (PDF)

Vendor Authorized Services

Vision Services need to be verified by Envolve Vision.
Professional Dental Services need to be verified by HCA.
Complex imaging, MRA, MRI, PET, and CT scans need to be verified by Evolent.
Interventional Pain Management services need to be verified by Evolent.
Musculoskeletal services need to be verified by Evolent. *Chiropractic specialty providers are NOT managed by Evolent.
Interventional Cardiovascular Services need to be verified by Evolent, effective January 1, 2026.

Behavioral Health

Behavioral Health/Substance Use Disorder requests can be submitted using our web portal or by fax. Please do not submit inpatient notifications via the web portal for Behavioral or Medicaid admissions.

Authorization Reminders

All Medical/Behavioral Inpatient and Outpatient Prior Authorization forms are on the Provider Manuals, Forms and Resources page.
Please note: we will need medical records supporting your request for services requiring a medical necessity review.
For Non-Urgent Preservice Decisions the plan has 5-14 days to make a determination. For Urgent Preservice Decisions the plan has 2-5 calendar days to make a determination.
All Tribal and Indian Health Care Providers are considered participating providers regardless if the provider is contracted with Coordinated Care or not.
All Department of Health recognized Neurodevelopmental Centers are exempt from Prior Authorization requirements
Please mark all discharge related Prior Authorization requests as “Urgent.” This includes but is not limited to: Post-Acute Care Facility, DME, Supplies, Home Services. The first 6 home health or home therapy visits following an inpatient discharge are automatically approved.

Prior Auth Requirements for Level of Care
LEVEL OF CARE REQUESTED	PLANNED (ELECTIVE) INPATIENT SURGERY/PROCEDURE	PLANNED OUTPATIENT (AMBULATORY) PROCEDURE	PLANNED OUTPATIENT PROCEDURE REQUIRING INPATIENT ADMISSION DURING OR AFTER PROCEDURE DUE TO COMPLICATIONS OR CHANGE IN OVERALL SURGICAL PROCEDURE
PRIOR AUTHORIZATION (PA) REQUIRED	*Yes,* always requires Prior Authorization	*Maybe,* Check Pre-Auth Check Tool for PA requirements by procedure code	*No,* notification of admission only
INSTRUCTIONS TO SUBMIT PA	Submit PA using Inpatient PA Fax Form or select Inpatient Procedure on web portal	Submit PA using Outpatient PA Form or as Outpatient on web portal	Notify Coordinated Care within 1 business day of Inpatient admit