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Apple Health (Medicaid) Pre-Auth

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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.

ALERT TO ALL ENTERAL PROVIDERS: In accordance with the changes to WAC 182-554-400 Enteral Nutrition, beginning August 27, 2022, Coordinated Care will allow up to a 10-day overlap in dates for processing of claims for refills delivered/shipped prior to the member exhausting their supply.

Announcement:
The planned implementation of National Imaging Associates, Inc. (NIA) review of interventional pain management, left heart catheterization and cardiac implant services has been delayed. No changes to clinical policies will be made on October 1, 2022 as previously announced. We tentatively plan an implementation in spring of 2023. More information will be shared as it becomes available.

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.  

 

Are services being performed in the emergency department or urgent care center or are these family planning services billed with a contraceptive management diagnosis?

Types of Services YES NO
Is this a planned elective admission to an Inpatient Hospital? (Excluding Labor & Delivery)
Is anesthesia being rendered for pain management?
Are oral surgeon services being rendered in office?

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 list (PDF) to see which drugs are covered by Fee for Service. These drugs are not paid for by Coordinated Care unless they are part of an inpatient admission.

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 NIA
  • Musculoskeletal Services need to be verified by Turning Point

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.
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