Patient Review and Coordination (PRC)

Information about the Patient Review and Coordination (PRC) program for providers.

Do you need more information for a client enrolled in an Apple Health managed care plan?

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What is 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
  • Hospital for non-emergency care
  • Narcotic prescriber

Clients in the PRC Program have shown a 33 percent decrease in ER use, 37 percent decrease in office visits, and a 24 percent decrease in prescriptions.

Looking for information for clients? Find client information on the Patient Review and Coordination (PRC) program web page.

How do I refer a client to the PRC program?

You can send a Patient Review and Coordination Referral Form by mail to:

PRC/PI
P.O. Box 45503
Olympia, WA 98504-5503

Or call 800-562-3022 ext. 15606

Referrals are accepted from private and public entities such as:

  • Providers
  • CSO office workers or other state or federal agencies
  • General population

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

  • Use the ProviderOne 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, narcotic prescriber, pharmacy and hospital. Any changes made will be in writing to the client, with a copy sent to the assigned provider.

What is my role?

Primary care provider (PCP)

  • Case manage client’s health care. Includes approval of additional care from other practitioners or specialists.
  • 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.

Assigned 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.
  • The Emergency Medical Treatment and Labor Act (EMTALA) require you to provide an appropriate medical screening examination to anyone who comes to your hospital emergency department. Emergency departments are not required to treat clients who have been screened and determined not to have an emergency medical condition.

How are clients assigned to a particular hospital?

The client will be given 10 days to choose a hospital for non-emergent care. If they do not chose they are assigned to a hospital close to their home.

What happens if a PRC client seeks services at a non-assigned hospital?

The hospital should follow its usual policy and procedures and bill accordingly. The hospital should contact the client's PCP to ensure he/she is aware of the services provided.

If the client is unable to give the name of a PCP, we ask the hospital to contact the PRC program at 800-562-3022 ext. 15606.

Narcotic prescriber

  • Manage the client's care and ensure the client receives appropriate narcotics 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.
  • If the client has a separate PCP, you must coordinate and collaborate with the PCP in the treatment of the client.
  • The client will be instructed to get narcotic prescriptions from only their assigned narcotic prescriber. The client’s assigned pharmacy will be notified of the narcotic prescriber and encouraged to contact the PCP if the client brings in a narcotic prescription from a non-assigned prescriber.

Assigned pharmacy

  • Manage the client's prescriptions by alerting the client's assigned PCP, narcotic prescriber, or a Washington Apple Health PRC staff of misuse or potential problems with the client's prescriptions.

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 non-assigned 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 for Point of Sale (POS) update.

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.

Clients should be encouraged to call their PCP’s office in order to avoid unnecessary emergency room visits.

How do I bill?

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

Additionally:

  • Hospitals do not need specific authorization to treat a PRC client.
  • Pharmacy: For Point of Sale (POS) and if the client is assigned to another pharmacy, call (800) 562-3022 ext. 15606.
  • Referrals to specialists require the primary care provider's National Provider Identification number in the ID# of referring physician box on the billing claim.

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

  • 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

How long will a client be assigned to a provider?

Clients are 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 with is required to allow assistance to find another assigned provider/pharmacy.

What if I suspect forgery or fraud?

If you suspect a client of forging a prescription, stealing a prescription pad or using someone's Medicaid Services Card you should:

Can I accept cash payment?

Contact

Phone: 1-800-562-3022 ext. 15606