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Medicaid Pre-Auth

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DISCLAIMER:

All attempts are made to provide the most current information on the Pre-Auth Needed Tool. However, this does NOT guarantee payment. Payment of claims is dependent on eligibility, covered benefits, provider contracts, correct coding and billing practices. For specific details, please refer to the provider manual. If you are uncertain that prior authorization is needed, please submit a request for an accurate response.

Please refer to the Prior Auth Quick Reference Guide (PDF) for questions.

 

Please check the State Medicaid Guidelines for Covered Benefits. Exclusions and limitations to these benefits can also be found on the Washington State Health Care Authority site. 

Vision Services need to be verified by Envolve Vision.
Dental Services need to be verified by DSHS.
Complex imaging, MRA, MRI, PET, and CT scans need to be verified by NIA.
Behavioral Health/Substance Abuse requests can be submitted using our web portal or by fax, using an OTR form (PDF).

For non-participating providers, Join Our Network.

 

All Inpatient and Outpatient Prior Authorization forms are on the Provider Manuals, Forms and Resources page.

Please note: we will need medical records supporting your request for services requiring a medical necessity review. Note for Non-Urgent Preservice Decisions the plan has 5-14 days to make a determination. For Urgent Preservice Decisions the plan has 2 calendar days to make a determination. For Standard Psychiatric Inpatient Services the plan has 12 hours of the receipt of the request to make a determination. For Urgent Concurrent and Post Stabilization Decisions the plan has 1 calendar day to make a determination. 

 

Are services being performed in the emergency department or urgent care center or are these family planning services billed with a contraceptive management diagnosis?

Types of Services YES NO
Is the member being admitted to an inpatient facility?
Are professional services being rendered in the home? (professional services do not include the delivery of DME, orthotics, prosthetics, or supplies).
Is anesthesia being rendered for pain management or dental surgery?
Are oral surgeon services being rendered in office?