Prior authorization (PA)

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:

  • How to submit an authorization request, and
  • The documentation required when submitting. 

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

  • Outpatient advanced imaging services
  • Select surgical procedures
  • Outpatient advanced imaging
  • Spinal injections, including diagnostic selective nerve root blocks

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

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.

The Health Care Authority’s (HCA) 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.

For questions about NCCI please refer to The National Correct Coding Initiative in Medicaid.

How?

On the Provider billing guides and fee schedules webpage:

  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 and fee schedules for that program or service.
  3. Open the appropriate billing guide and/or fee schedule based on the date of service to search for the code or service.

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.

For a complete list, visit our Provider billing guides and fee schedules webpage.

Step 3: Find and complete forms

All services or items requiring prior authorization must be submitted on the General Information for Authorization (form 13-835), 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: How to submit a PA request

There are three options for submitting a request:

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.

Note: The General Information for Authorization form (13-835) must be typed and be page 1 of your fax to avoid delays. Do not include a fax coversheet.

By mail

Complete the General Information for Authorization form (13-835) with all supporting documentation and mail it to:

Authorization Services Office
PO Box 45535
Olympia, WA 98504-5535

Fax or mail submissions

Use one of the following two options when you fax or mail your submissions:

  • FastLook™ and FastAttach™ services provided by National Electronic Attachment, Inc. (NEA)
    Register with NEA by visiting www.nea-fast.com and entering “FastWDSHS” in the blue promotion code box.
    Contact NEA at: 1-800-782-5150, ext. 2, with any questions.

Note: When this option is chosen, fax your request to the agency and indicate the NEA# in the NEA field on the PA request form. There is a cost associated which will be explained by NEA.

  • Mail x-rays/photos with the requests to:
    Authorization Services Office
    ​PO Box 45535
    Olympia, WA 98504-5535

Instructions for mailing requests

If you choose to mail your requests, the agency requires you to:

  • Place x-rays in a large envelope.
  • Attach the General Information for Authorization form (13-835) and any other additional pages to the envelope (i.e. tooth chart, perio charting etc.). No staples.
  • Put the client’s name, ProviderOne ID#, and service type the request is for on the envelope.

Note: For orthodontics, write “orthodontics” on the envelope.

  • Place in a larger envelope for mailing. Multiple sets of requests can be mailed together.
  • Mail to the agency.

Barcode document submission cover sheets

When submitting supporting documents to an already existing authorization. Please use one of the following:

Step 5: Check the status of an authorization

Use any of the following tools to learn how to check the status of your authorization:

Expedited prior authorization (EPA)

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

To view a list of qualifying services, download our EPA inventory.

Criteria

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

Guidelines

  • The EPA number must be used when the provider bills the agency. 
  • Upon request, a provider must provide documentation to the agency showing how the client's condition meets all the criteria for EPA. 
  • A written request for prior authorization is required when a situation does not meet all the EPA criteria.
  • The agency may recoup any payment made to a provider if the provider did not follow the required EPA process and if not all of the specified criteria were met.

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 post-payment review and audit by the agency or its designee.

Contact

Toll-free: 1-800-562-3022, extensions:
Hours: ​Monday through Friday 8 to 11:45 a.m. and 1 to 4:30 p.m., except where noted

  • Durable medical equipment (DME): 15466
  • Medical: 15471
  • Pharmacy: 15483
    Hours: ​Monday through Friday 8:30 a.m. to 4:30 p.m.
  • Qualis: 52018
  • Dental: 15468
    Hours: ​Monday through Thursday, 8 to 11:30 a.m.

Prior authorization fax line: 1-866-668-1214