Transhealth program

Program overview

Apple Health (Medicaid) has an extensive Transhealth program. For details, see the Transhealth program billing guide.

Washington Apple Health (Medicaid) covers a variety of services for our enrolled clients. Each provider must enroll with the Health Care Authority to serve our clients. We are actively recruiting new providers for this program.

Provider enrollment

If you are interested in enrolling as a provider, refer to our Billers, providers and partners website for information on Provider enrollment. This website has the links necessary for enrolling as a provider. You can also call 1-800-562-3022 and request provider enrollment for assistance with the enrollment process.

Gender-affirming interventions and treatment

Apple Health covered medical services for gender-affirming treatment include, but are not limited to:

Services covered through fee-for-service

• Surgical consults
• Hospitalizations and physician services related to procedures performed for gender-affirming surgery
• Hospitalizations and physician services related to postoperative complications of procedures performed for gender-affirming surgery
• Medically necessary, gender-affirming hair removal

Services covered through the MCO

The following are covered through the client's HCA-contract MCO:

• Physician services
• Hormone therapy
• Puberty suppression therapy
• Speech therapy (including voice training)
• Behavioral health services
• Labs
• Pathology
• Radiology

A health care provider with experience prescribing and/or delivering gender affirming treatment must review and confirm the appropriateness of any adverse benefit determination.

Services overview

Apple Health pays for consultations related to gender-affirming treatment and associated electrolysis or laser hair removal required for gender reassignment surgery (GRS). To ensure payment, bill ProviderOne directly for this consultative visit using an expedited prior authorization (EPA) number. For instructions on billing using EPA, see the transhealth billing guide.

For instructions on how to obtain prior authorization, see the transhealth billing guide.

Gender affirming treatment

Gender affirming treatment services to treat gender dysphoria are covered for clients who have a diagnosis of gender dysphoria (ICD codes F64.0, F64.1, F64.2 and F64.9). Prior authorization is required through ProviderOne.

Under this program:

• Apple Health authorizes and pays for only medically necessary services.
• Providers must be enrolled with Apple Health.
• Apple Health may cover transportation services to and from medical appointments.
• Any out-of-state care, including a presurgical consultation, must be prior authorized as an out-of-state service.
• Apple Health does not pay for procedures and surgeries related to reversal of gender-affirming surgery.

General requirements

It is a general requirement that the client has:

• Been on gender affirming hormone therapy for a minimum of 12 months preceding surgery (with the exception of mastectomy/reduction mammoplasty), or have
  • A medical contraindication to hormone therapy.
• Lived in a gender role that is congruent with their gender identity for a minimum of 12 months preceding surgery, (with the exception of mastectomy/reduction mammoplasty, orchiectomy and hysterectomy), or
  • Been unable to live in their desired gender identity due to personal safety concerns.

Required documentation

The provider must include the required documentation with the prior authorization request. The documentation must be signed, and dated by the provider and in letter format, except for the surgeon's History & Physical, and surgical plan. Please see the transhealth billing guide for the documentation requirements for specific gender affirming treatments/procedures.

Prior authorization and request for additional information

The ProviderOne Billing and Resource Guide provides a step-by-step resource to help providers and billing staff understand the processes of ensuring clients are eligible for services and to receive timely and accurate payments for covered services.

Instructions for submitting a prior authorization request

A prior authorization (PA) can be submitted:

• Online, which is strongly encouraged. When submitting online you will receive a reference number (PA number) immediately that you can use to check the status of your request. View the prior authorization webpage for details.
• Via fax to 1-866-668-1214.  If providers choose to submit a PA request via fax, the following documentation must be provided:
  • The General Information for Authorization form HCA 13-835. This form must be page one of the faxed requests and must be typed.
  • The program form: This form is required for out-of-state requests for transhealth services.
  • Required documentation (i.e., psychosocial evaluations, letter from Primary Care Provider (PCP) or provider providing hormone therapy, H&P and surgical plan from surgeon, etc.) to support the request for authorization.
  • Fax PA request with forms and required documentation to 1-866-668-1214.
  • Include all information requested above. HCA returns incomplete requests to the provider.

Instructions for submitting additional information on a pended PA

Additional information on a pended PA can be submitted:

• Online. View instructions on the prior authorization webpage.
• Via fax to 1-866-668-1214.
  • Use the PA Pend Forms Submission Cover Sheet.
  • Type the 9-digit Reference Number from your letter into the Authorization Reference # field and hit Enter (this will expand the barcode shown).
  • Click on the "Print Cover Sheet" button; choose "Yes" if you are asked whether you want to allow the document to print.
  • Fax the barcode sheet as the first page (no coversheet), followed by the supporting documents to 1-866-668-1214.