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Apple Health (Medicaid) has an extensive Transhealth program. For details please see the Transhealth program section of the Physician-Related Services/Health Care Professional Services 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.
Apple Health covered medical services for gender-affirming treatment include, but are not limited to:
- Presurgical and postsurgical hormone therapy
- Puberty suppression therapy
- Behavioral health services
- Surgical and ancillary services including:
- Physician services
- Hospitalizations and physician services related to postoperative complications of procedures performed for gender-affirming surgery
Behavioral health services and hormone therapy, including puberty blockers, are covered under Apple Health and paid for through the client's managed care organization (MCO).
Other gender affirming treatments are covered by Apple Health fee-for-service (ProviderOne), and not through the client's MCO. These services have specific criteria and require prior authorization through ProviderOne before the client receives the service.
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 Physician-Related Services/Health Care Professional Services Billing Guide.
For instructions on how to obtain prior authorization, see the Physician-Related Services/Health Care Professional Services Billing Guide.
Surgical 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 of surgical services must be enrolled with Apple Health.
- Apple Health may cover transportation services to and from medical appointments.
- Any out-of-state care, including a pre-surgical 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.
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.
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 Physician-Related Services/Health Care Professional Services Billing Guide for the specific documentation requirements.
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.
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 evals, 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.
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.