Wash. Admin. Code § 182-543-7000 - Authorization

(1) The medicaid agency requires providers to obtain authorization for medical equipment as required in this chapter, in chapters 182-501 and 182-502 WAC, and in published billing guides and provider notices or when the clinical criteria required in this chapter are not met.

(a) The agency considers requests for prior authorization (PA) for any item meeting the definition of medical equipment, and PA is granted when the service is medically necessary as defined in WAC 182-500-0070.

(b) For prior authorization (PA), a provider must submit a written request to the agency as specified in the agency's published billing guides (see WAC 182-543-7100 ). All requests for prior authorization must be accompanied by a completed General Information for Authorization form (HCA 13-835) in addition to any program specific forms as required within this chapter. The agency's electronic forms are available online at http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx.

(c) For expedited prior authorization (EPA), a provider must meet the clinically appropriate EPA criteria outlined in the agency's published billing guides. The appropriate EPA number must be used when the provider bills the agency (see WAC 182-543-7200 ).

(2) When a service requires authorization, the provider must properly request authorization in accordance with the agency's rules, billing guides, and provider notices.

(3) The agency's authorization of services does not necessarily guarantee payment.

(4) When authorization is not properly requested, the agency rejects and returns the request to the provider for further action. The agency does not consider the rejection of the request to be a denial of service.

(5) Authorization requirements in this chapter are not a denial of service to the client.

(6) The agency may recoup any payment made to a provider if the agency later determines that the service was not properly authorized or did not meet the EPA criteria. Refer to WAC 182-502-0100(1)(c).

Notes

Wash. Admin. Code § 182-543-7000

Amended by WSR 14-08-035, filed 3/25/14, effective 4/25/2014 Amended by WSR 18-24-021, Filed 11/27/2018, effective 1/1/2019

11-14-075, recodified as §182-543-7000, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. 11-14-052, § 388-543-7000, filed 6/29/11, effective 8/1/11.