PDFWAC 182-531-0200

Physician-related and health care professional services requiring prior authorization.

(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.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-03-049, § 182-531-0200, filed 1/10/24, effective 2/10/24; WSR 15-16-084, § 182-531-0200, filed 7/31/15, effective 8/31/15. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-531-0200, filed 7/25/13, effective 9/1/13. 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.]