Step-by-step guide for prior authorization

Many procedures require prior authorization (PA) before you can treat your patients. Our goal is to make this process as easy as possible. This section provides information on:

Note: The agency contracts with Comagine Health to provide web-based access for reviewing medical necessity for the following Apple Health (Medicaid) services:

To learn more about Comagine Health, view "Medical Necessity Review by Comagine Health" in the Physician-related/health care professional services billing guide.

On this page

Step 1: Check client eligibility

Log into ProviderOne to determine if your client is eligible for the service(s) or treatment(s) you wish to provide. Learn how using our Successful eligibility checks using ProviderOne fact sheet.

Note: If the client is in a managed care plan, please contact the plan for coverage and prior authorization requirements. To access other health plans, visit OneHealthPort.

Step 2: Determine if a code or service requires prior authorization

Use our provider billing guides and fee schedules to review policy and find out whether a code or service requires prior authorization.

National Correct Coding Initiative (NCCI)

HCA's authorization services do not consider National Correct Coding Initiative (NCCI) guidelines when processing a request. Make sure your office checks the NCCI guidelines prior to submission.

Important: Inadvertently approved authorizations do not guarantee claims payment.

How?

  1. Find the program or service that corresponds to the service(s) or item. (Programs and services are listed in alphabetical order.)
  2. Click the program or service name to expand the listing. Here you will find billing guides, fee schedules, preferred drug list (PDL), and expedited authorization codes and criteria for that program or service.
  3. Open the appropriate billing guide, fee schedule and/or other resources based on the date of service to search for the code, service or drug.

Important: Check the code or service in the fee schedule and provider guide for where the services will be performed. You may have to check multiple schedules or guides based on place of service. For example: Check the physician fee schedule and the ambulatory surgery center (ASC) fee schedule if you are performing the service in an ASC to:

  1. Make sure that it is covered for the location where you are performing the service, and
  2. See whether a PA is required for that place of service.

Billing guide/fee schedule quick links

The following is a shortened list of regularly used billing guides and fee schedules.

Step 3: Find and complete forms

Services or items requiring prior authorization must be submitted on the General Information for Authorization (form 13-835), or for drugs submitted through the pharmacy point of sale (POS) system the Pharmacy Information Authorization (form 13-835A). Each individual service or item may require additional forms. View a list of all prior authorization forms on our Forms and publications webpage.

Commonly used forms

One of the following forms is required to initiate the prior authorization process.

Step 4: Submit a PA request

Submit by mail not available at this time: The agency is no longer accepting prior authorizations requests or supporting documentation by mail. Please submit by direct data entry or by fax.

By direct data entry (DDE) in the ProviderOne portal

Providers can direct data enter authorization requests directly into the ProviderOne System. This feature includes the ability to attach records, color photos, and x-rays. Upon successful submission, a provider will receive a 9-digit reference number; the reference number is verification that the agency has received your request. Providers must not bill or perform a procedure(s) until the agency has provided written approval. This new function does not change the way the agency processes prior authorization requests, the agency will still process requests in the order received. Please ensure that when submitting a prior authorization request that the required documentation is included along with a fax number. See the self-service training resources below:

By fax

Complete the General Information for Authorization form (13-835) with all supporting documentation and fax it to: 1-866-668-1214.

For drugs submitted through the pharmacy point-of-sale (POS) system, complete the Pharmacy Information Authorization form (13-835A) and fax to 1- 833-991-0704.

Note: Form 13-835 and 13-835A must be typed and be page 1 of your fax to avoid delays. Do not include a fax coversheet.

Submit x-rays or photos (if required)

Fax submissions

Use FastAttach TM services provided by Vyne Dental (formerly NEA).

  1. If you are not already registered, register at reg.nea-fast.com. For more information contact: 1-800-782-5150, ext. 1.
  2. Fax your request to the agency and indicate the FastAttach# in the NEA #18 field on the PA request form.

There is a cost associated which will be explained by Vyne Dental.

Submit supporting documentation to an existing authorization

For general PA requests, use the following cover sheet when submitting supporting documents to an already existing authorization: For example, when responding to a pend for additional information, or an existing approved authorization requires a billing code or NPI update.

For drugs submitted through the pharmacy point-of-sale (POS) system, a barcode coversheet is not required. Submit supporting documentation by:

Step 5: Check the status of an authorization or retrieve correspondence

Learn how to check authorization information in ProviderOne.

Expedited prior authorization (EPA)

The EPA process is designed to eliminate the need for written requests for prior authorization for selected services/items.

Criteria

Following certain criteria, the agency allows for use of an EPA. Criteria are explained in each of the program provider guides.

Guidelines

Note: By entering an EPA number on your claim, you attest that all the EPA criteria are met and can be verified by documentation in the client's record. These services are subject to postpayment review and audit by the agency or its designee.

Contact

Toll-free: 1-800-562-3022

Prior authorization fax line:

Related forms and publications

Related links

Connect with us

Copyright © 2024 Washington Health Care Authority