Important: Stay covered! Are you enrolled in Apple Health (Medicaid) coverage? It may be time to complete your renewal. Make sure your address and phone number are up to date so you can stay enrolled. Report a change.
The Patient Review and Coordination (PRC) Program is a Medicaid health and safety program that coordinates care and ensures clients enrolled in PRC use services appropriately and in accordance with agency rules and policies. This program allows the agency to restrict clients to certain providers.
Many clients are seen by several different providers, have a high number of duplicative medications, use several different pharmacies, and have a high emergency room usage. Based on clinical and utilization findings, clients are placed in the PRC program for at least two years.
The PRC program may assign the client to a specific provider(s) chosen either by the client or assigned by the program. Clients can be assigned to one primary care provider (PCP), one pharmacy, one controlled substances prescriber or any combination of these providers. The assigned PCP will coordinate the client's health care needs, and monitor and educate clients about the appropriate use of services.
The program has looked at your use of health care services, and our information and records show that you may have either overused or did not use health care services appropriately. Out of concern for your health and safety, this program is here to support coordination of the care you're getting.
For clients who have Apple Health coverage without a managed care plan (also known as fee-for-service), contact the Health Care Authority (HCA) PRC program:
If you are enrolled in an Apple Health (Medicaid) managed care plan (MCO), you will need to contact the MCO PRC Program for the plan you are enrolled with for assistance using the numbers below:
| Plan | Phone number |
|---|---|
| Amerigroup (AMG) | 206-471-7328 |
| Community Health Plan of Washington (CHPW) | 1-866-907-1902 |
| Coordinated Care of Washington (CCW) | 1-833-236-4818 |
| Molina Healthcare of Washington, Inc. (MHW) | 1-866-325-6411 |
| UnitedHealthcare Community Plan (UHC) | 1-877-314-1096 |
Most clients enrolled in the PRC program can change MCOs after 12 months. You can also change MCOs if your current MCO is not available in the area you live in.
You're assigned to a provider for at least one year. After one year you can choose to change to a different provider. If you move out of the area or your provider moves out of the area or your provider can no longer manage your care, you can change your providers. To change a provider, you need to call your PRC program.
There are exceptions to the 12-month rule which are described in WAC. See WAC 182-501-0135Â for additional information.
Here's a list of services that do not need a referral:
Yes, you can get transportation to most health care appointments. If you need transportation to a health care appointment, you can call the transportation coordinator for your area and ask about the types of services offered. Visit Transportation Services (nonemergency) to locate a Transportation Coordinator.
You may ask for a hearing according to WAC 182-501-0135 if you disagree with the decision of your enrollment in the PRC program. The hearing must be requested within 90 days from the date of your initial placement letter. If you're enrolled in an Apple Health (Medicaid) managed care plan (Amerigroup of Washington, Coordinated Care of Washington, Community Health Plan of Washington, Molina Healthcare or UnitedHealth Care) you'll need to contact your plan for assistance.
Visit the Office of Administrative Hearings website for more information about your hearing rights.
You have two options to request a hearing: