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Prior Authorization

Prior Authorization

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In a survey of WSMA members, prior authorization—with its numerous requirements, ever-changing criteria, and reliance on outdated technology (fax machines and 800 numbers)—was identified as the paramount administrative challenge faced by physicians and practices.

Accordingly, Healthy Doctors, Healthier Patients, WSMA's initiative to improve professional satisfaction among physicians by addressing the causes of burnout, made improving prior authorization processes it's number one goal.

New state rules and the WSMA Prior Authorization Navigator

In January 2018, new state rules streamlining and standardizing prior authorization programs for medical services used by Washington insurers* went into effect, marking the culmination of years of negotiation between the WSMA, the Washington State Hospital Association, and the Office of the Insurance Commissioner (OIC), and representing a major victory in the WSMA's Healthy Doctors, Healthier Patients initiative. The new regulations clarify definitions, set timelines for standard and expedited requests, establish clear communication requirements and much more. Similar OIC rules for prescription drug prior authorization programs passed in 2015.

To help you adjust your workflows to accommodate the new requirements, the WSMA has introduced the Prior Authorization Navigator—a mobile-friendly "one-stop-shop" website for guidance on the new rules. On the Navigator, you'll find a one-minute bullet-point summary of the new rules as well as in-depth guidance on the rules' provisions. You'll also find guidance on 2015 rules covering prior authorization of prescription drugs.

Visit the WSMA Prior Authorization Navigator.

Download a one-pager for quick reference for your staff or your office.

*The new rules apply to plans the OIC regulates: Individual (both on and off the Washington Health Benefit Exchange) and small and large groups (other than self-insured). The rule does not apply to Medicaid managed care organizations and Medicaid fee-for-service plans, Medicare, Taft-Hartley plans, PEBB/Uniform Medical and Tricare.

Apple Health (Medicaid) prior authorization resources

The Health Care Authority now allows physicians and providers caring for patients enrolled in Apple Health or the Public Employees Benefits Board to submit prior authorizations for medical requests and all backup documentation online.

Visit the HCA's dedicated prior authorization webpage.

Other resources

OneHealthPort offers an online directory of payer website links and instructions for pre-authorizations and admission notifications. With OneHealthPort's Pre-Service Directory you can:

  • Choose a payer from a simple drop-down list.
  • Choose a coverage plan and access information such as admission notifications, advanced imaging services, general pharmacy services, mental/behavioral health, and special instructions on visits/procedures, and services such as physical medicine, sleep management, hospice, and more.
  • See what services are "carved out" (provided by an outside service).
  • Access the latest changes to payer data.

OneHealthPort Pre-Service Directory.

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