Health care coverage—Process for submitting a valid request for authorization.
(1) The department requires providers to obtain authorization for certain health care services in accordance with this section, chapters 388-501
WAC, other applicable department rules, current published department billing instructions, and/or numbered memoranda. For the purposes of this section, health care services include treatment, equipment, related supplies, and drugs.
(a) For health care services that require prior authorization (PA), a provider (as defined in WAC 388-500-0005
) must submit a written, electronic, or telephonic request to the department. To be a valid request for prior authorization, the provider must submit the request and conform to the department's current published program billing instructions, numbered memoranda, and any additional requirements in Washington Administrative Code (WAC) and/or Revised Code of Washington (RCW).
(b) For expedited prior authorization (EPA), a provider must certify that the client's clinical condition meets the appropriate EPA criteria outlined in the department's current published program billing instructions, numbered memoranda, and any additional requirements in WAC and/or RCW. The provider must use the department-assigned EPA number when submitting a claim for payment to the department.
(c) The department requires prior authorization for covered health care services when the applicable expedited prior authorization criteria are not met.
(d) Upon request, a provider must submit documentation to the department showing how the client's condition meets the required criteria for PA or EPA.
(2) Department authorization requirements for covered health care services are not a denial of service.
(3) The department returns invalid requests to the provider and takes no further action unless the request for authorization is resubmitted. The return of an invalid request is not a denial of service.
(4) Failure of a provider to request authorization for a health care service that requires it or a provider's failure to do so properly is not a denial of service.
(5) The department's authorization of health care service(s) does not guarantee payment. See WAC 388-501-0050
for other general requirements that must be satisfied before payment can be made for a health care service requested and authorized under this section.
(6) The department evaluates a request for an authorization of a health care service that exceeds identified limitations, on a case-by-case basis and in accordance with WAC 388-501-0169
(7) The department may recoup any payment made to a provider if the department later determines the health care service was not properly authorized or did not meet EPA criteria. Refer to chapters 388-502
[WSR 11-14-075, recodified as § 182-501-0163, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050
, 74.08.090, 74.09.530, and 74.09.700. WSR 09-23-112, § 388-501-0163, filed 11/18/09, effective 12/19/09.]