Current through Register Vol. 24-18, September 15, 2024
(1)
The medicaid agency requires prior authorization for certain
services. Prior authorization includes expedited prior authorization
(EPA) and limitation extension (LE). See WAC
182-501-0165.
(2) EPA is designed to eliminate the need for
written authorization. The agency establishes authorization criteria and
identifies the criteria with specific codes, enabling providers to use that EPA
number if a client meets the EPA criteria.
(a)
The provider must create an authorization number using the process explained in
the medicaid agency's physician-related billing instructions.
(b) Upon request, the provider must provide
supporting clinical documentation to the medicaid agency showing how the
authorization number was created.
(c) Selected nonemergency admissions to
contract hospitals require EPA. These are identified in the medicaid agency
billing instructions.
(d)
Procedures allowing expedited prior authorization include, but are not limited
to, the following:
(i) Reduction
mammoplasties/mastectomy for gynecomastia;
(ii) Strabismus surgery for clients 18 years
of age and older;
(iii)
Meningococcal vaccine;
(iv)
Placement of drug eluting stent and device;
(v) Cochlear implant devices;
(vi) Hyperbaric oxygen therapy;
(vii) Visual exam/refraction for clients 21
years of age and older;
(viii)
Blepharoplasties; and
(ix)
Neuropsychological testing for clients 16 years of age and older.
(3) The medicaid agency
evaluates new technologies under the procedures in WAC
182-531-0550. These require prior
authorization.
(4) Prior
authorization is required for the following:
(a) Abdominoplasty;
(b) All inpatient hospital stays for
acute physical medicine and rehabilitation (PM&R);
(c) Cochlear implant devices (refer to WAC
182-531-0375);
(d) Diagnosis and treatment of eating
disorders for clients 21 years of age and older;
(e) Osteopathic manipulative therapy in
excess of the medicaid agency's published limits;
(f) Panniculectomy;
(g) Bariatric surgery (see WAC
182-531-1600);
(h) Vagus nerve stimulator insertion, which
also:
(i) For coverage, must be performed in
an inpatient or outpatient hospital facility; and
(ii) For reimbursement, must have the invoice
attached to the claim.
(i) Osseointegrated/bone anchored hearing
aids (BAHA) for clients 20 years of age and younger;
(j) Removal or repair of previously implanted
BAHA or cochlear implant devices for clients 21 years of age and older when
medically necessary; and
(k) Gender
reassignment surgery (see WAC
182-531-1675).
(5) All hysterectomies performed for medical
reasons may require prior authorization, as explained in subsection (2) of this
section.
(a) Hysterectomies may be performed
without prior authorization in either of the following circumstances:
(i) The client has been diagnosed with
cancer(s) of the female reproductive organs; and/or
(ii) A hysterectomy is needed due to
trauma.
(b) The agency
reimburses all attending providers for a hysterectomy procedure only when the
provider submits an accurately completed agency-approved consent form with the
claim for reimbursement.
(6) The medicaid agency may require a second
opinion and/or consultation before authorizing any elective surgical
procedure.
(7) Children six years
of age and younger do not require authorization for hospitalization.
WSR 11-14-075, recodified as §182-531-0200, filed
6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.08.090. WSR 11-14-055, §
388-531-0200, filed 6/29/11, effective 7/30/11; WSR 10-19-057, §
388-531-0200, filed 9/14/10, effective 10/15/10. Statutory Authority:
RCW
74.08.090,
74.09.520. WSR 05-12-022, §
388-531-0200, filed 5/20/05, effective 6/20/05; WSR 01-01-012, §
388-531-0200, filed 12/6/00, effective
1/6/01.
