Patient Review and Coordination (PRC)

What happens when a client is enrolled in the Patient Review and Coordination (PRC) program?

A PRC client may be assigned to specific provider(s) that are either chosen by the client or assigned by the program. PRC clients can be assigned to one or any combination of the following provider types:

• Primary care provider
• Pharmacy
  • To accommodate any access to care concerns, a client may be assigned to more than one pharmacy
• Hospital for nonemergency care
• Controlled substances prescriber (CSP)

Client enrolled with managed care plan

Is your client enrolled in an Apple Health managed care plan? If so, you must contact the MCOs at the PRC contacts listed below.

How do I refer a fee-for-service client to the PRC program?

You can send a Patient Review and Coordination Referral Form by email to the HCA PRC program.

Or call 800-562-3022 ext. 15606

Referrals are accepted from private and public entities such as:

• Medical providers
• Social service agencies
• Other concerned parties

How do I know who a PRC client is assigned to?

• Use the Benefit Inquiry screen in ProviderOne to see who a client is assigned to.
• Call HCA customer service provider line at 800-562-3022 to check a client’s eligibility and assigned providers.
• Assigned providers receive a copy of the client letter that notifies the client of the assigned PCP, controlled substances prescriber (CSP), pharmacy and hospital.

What is my role?

Primary care provider (PCP)

• Manage and coordinate the client’s health care.
• Educate the client on appropriate use of services.
• Make referrals. As the client's PCP, you can refer the client to a specialist or other provider.
  • Referral to a specialist or another primary care provider requires the assigned PCP's National Provider Identification (NPI) on the billing claim.

Can another provider in my clinic or the provider on call see my PRC client?

If you are not available, another provider or the provider on call in the PCP’s clinic may see the PRC assigned client. Your NPI number must be in the referring box on the billing claim or the bill may be denied.

Hospital

• Assist the PCP to effectively manage care to avoid unnecessary and costly services, especially emergency room services. You should refer the client back to their PCP whether treatment is provided or not. Contacting and consulting with the client's PCP ensures that the PCP is aware of the client's use of services.
• Hospitals do not need specific authorization to treat a PRC client.

Controlled substances prescriber

• Manage and coordinate the client's care in collaboration with the PCP
• Ensure the client received only the appropriate controlled substances for their medical needs.
• Educate the client on appropriate use of narcotics and pain management to assist the client work towards compliance and self-management.
• The client will be instructed to get controlled substances prescriptions from only their assigned controlled substances prescriber.

Assigned pharmacy

• Manage the client's prescriptions.
• Alert the client's assigned PCP or controlled substances prescriber of any misuse or potential problems with the client's prescriptions, including but not limited to:
  • Forgeries
  • Unauthorized use of a client's Apple Health services card

Do all prescriptions require prior authorization?

No. All Medicaid pharmacy policies remain in effect regarding prior authorization.

What if the client needs medications prescribed by the emergency room, after hours, or while visiting another area using a nonassigned pharmacy?

You may fill the prescription per emergency fill procedure in the agency's Medicaid provider billing guides and then call the Patient Review and Coordination referral line at 1-800-562-3022 ext. 15606 the next business day.

What if the client has an emergency and the assigned provider is not available?

Washington Apple Health clients can go to the emergency room for an emergency medical condition (including labor and delivery) as established by the guidelines in WAC 182-500-0030.

How do I bill for a fee-for-service client?

Follow the agency's Medicaid provider billing guides. Any claims by a nonassigned primary care provider or pharmacy may not be paid.

In addition, specialist billing requires the primary care provider’s National Provider Identification number in the ID# of referring physician on the claim.

The following services/providers do not need a referral from the PCP to be billed:

• Behavioral health agency
• Dental services
• Substance use disorder (SUD) treatment facilities
• Drug treatment facilities
• Emergency services
• Family planning agencies
• Health department
• Home health agencies
• Hospice
• Long term care
• Medical transportation services (emergent and nonemergent)
• Medical equipment
• Renal dialysis center
• Transportation services
• Vision care/optometrist

How long will a client be assigned to a provider?

Clients are assigned to the same provider for a minimum of one year. After one year, the client can request to change providers.

Clients are enrolled in the PRC Program for a minimum of two years.

Assigned providers can terminate the relationship with the PRC client at any time. However, 30-day notice to the PRC client and notification to the PRC Program is required to allow assistance to find another assigned provider/pharmacy.

Can I accept cash payment?

• See the Billing a client WAC 182-502-0160 (1)(2).