(1) The medicaid agency requires prior authorization (PA) for certain services.
(a) Procedures or services requiring PA are identified in applicable agency billing guides and fee schedules.
(b) When requesting PA, providers must follow WAC 182-501-0163 and 182-501-0169.
(c) The agency reviews PA requests according to WAC 182-501-0165.
(2) The agency evaluates experimental and investigational services under WAC 182-531-0550. Experimental and investigational services require PA.
(3) All hysterectomies performed for medical reasons may require PA.
(a) Hysterectomies may be performed without PA in either of the following circumstances:
(i) The client has been diagnosed with cancer(s) of the female reproductive organs; or
(ii) A hysterectomy is needed due to trauma.
(b) The agency pays all attending providers for a hysterectomy procedure only when the provider submits an accurately completed agency-approved consent form with the claim for payment.
(4) The agency may require a second opinion or consultation before authorizing any elective surgical procedure.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 26-17-080, s 182-531-0200, filed 8/17/26, effective 9/17/26; WSR 24-03-049, § 182-531-0200, filed 1/10/24, effective 2/10/24; WSR 15-16-084, § 182-531-0200, filed 7/31/15, effective 8/31/15. Statutory Authority: RCW 41.05.021, 74.09.520, 74.09.657, 74.09.659, and 74.09.800. WSR 13-16-008, § 182-531-0200, filed 7/25/13, effective 9/1/13. WSR 11-14-075, recodified as § 182-531-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090. WSR 11-14-055, § 388-531-0200, filed 6/29/11, effective 7/30/11; WSR 10-19-057, § 388-531-0200, filed 9/14/10, effective 10/15/10. Statutory Authority: RCW 74.08.090, 74.09.520. WSR 05-12-022, § 388-531-0200, filed 5/20/05, effective 6/20/05; WSR 01-01-012, § 388-531-0200, filed 12/6/00, effective 1/6/01.]