Patient review and coordination

What is the Patient Review and Coordination Program?

The Patient Review and Coordination (PRC) Program is a federal and state requirement of Medicaid that focuses on the health and safety of clients. It's used by both the state and the Apple Health managed care plans to control the over-utilization and inappropriate use of medical services by clients, by allowing restrictions of clients to certain providers.

If you are enrolled in an Apple Health (Medicaid) managed care plan (Amerigroup of Washington, Coordinated Care of Washington, Community Health Plan of Washington, Molina Healthcare or UnitedHealth Care) you will need to contact your plan for assistance.

Many of the clients are seen by several different providers, have a high number of duplicative medications, use several different pharmacies, and have a high emergency room usage. Based on clinical and utilization findings, clients are placed in the PRC program for at least two years.

The PRC program may assign the client to a specific provider(s) chosen either by the client or assigned by the program. Clients can be assigned to one primary care provider, one pharmacy, one hospital for non-emergency care, one narcotic prescriber or any combination of these providers. The assigned provider will coordinate the client's medical needs, and monitor and educate clients about the appropriate use of services.

Clients who have been on the PRC program have shown a decrease in the inappropriate use of medical services.

Why am I on this program?

The program has looked at your use of medical services, and our information and records show that you either over used or did not use medical services correctly. Out of concern for your health and safety we're trying to coordinate the care you're getting.

When can I change providers?

You're assigned to a provider for at least one year. After one year you can choose to change to a different provider. Also, if you move out of the area or your provider moves out of the area, you can change your provider by calling a PRC program specialist. If your provider decides they can no longer manage your care, you'll need to contact your program specialist so we can help you find a new provider.

Do I need a referral for every provider?

Here's a list of services that do not need a referral:

  • Community mental health center
  • Dental services
  • Drug treatment facilities
  • Emergency services
  • Family planning agencies
  • Health department
  • Home health agencies
  • Hospice
  • Long term Care
  • Medical transportation services
  • Medical equipment
  • Renal dialysis center
  • Transportation services
  • Vision Care/optometrist

However, if we see that you're not using any of these services correctly, your assignment may include providers of these services.

Can I get transportation to medical appointments?

Yes, you can get transportation to most medical appointments. If you need transportation to a medical appointment, you can call the transportation coordinator for your area and ask about the types of services offered. Visit Transportation Services (non-emergency) to locate a Transportation Coordinator.

What are my hearing rights?

You may ask for a hearing according to WAC 182-501-0135 if you disagree with the decision of your enrollment in the PRC program. The hearing must be requested within 90 days from the date of your initial placement letter. If you're enrolled in an Apple Health (Medicaid) managed care plan (Amerigroup of Washington, Coordinated Care of Washington, Community Health Plan of Washington, Molina Healthcare or UnitedHealth Care) you'll need to contact your plan for assistance.

  • You have the right to have legal counsel or another person represent you at the hearing. You may get free legal counsel from a Legal Services Office.
  • If you ask for a hearing within ten (10) calendar days of placement in this program, you wont be enrolled in the Patient Review and Coordination program until an order is issued placing you in the PRC program.

Visit the Office of Administrative Hearings website for more information about your hearing rights.

How do I ask for a hearing?

You have two options to request a hearing:

  • Write to Office of Administrative Hearings, P.O. Box 42489, Olympia, Washington 98504-2489.
  • Call 1-800-583-8271.

Be sure you include a copy of your initial restriction letter with your request for a hearing.

What other resources are available?

  • Dial 211 to learn about other resources that may be available.
  • Call HCA's Medical Assistance Customer Service Center: 1-800-562-3022.
  • See which Transportation Services are available to get you to and from medical services.
  • You can seek drug alcohol and substance abuse services for help.
  • Contact mental health services, including crisis lines and suicide prevention help.
  • Report Child Abuse or Abuse of an Elderly or Disabled Person: Call 1-866-END-HARM (1-866-363-4276)
  • Find services related to medical, legal, shelter, counseling and/or anger management: Call 1-800-562-6025 for 24-hour information.
  • Washington Poison Center: 1-800-732-6985 for 24-hour information and advice regarding poisonous substances and overdoses.