Washington WA

Washington is one of two states (with CO) publicly leading CMS-0057-F implementation. WA HB 1357 directs HCA to stand up a FHIR Prior Authorization Workgroup; HCA has published an interop roadmap targeting the Jan 2027 effective date. Distinguishes WA from the ~40 states that have made no public CMS-0057-F commitment for Medicaid.

single_PDL_unified_clinical_PA_criteria

State-controlled Apple Health Single PDL governs all MCOs and FFS uniformly; MCOs administer claims through their own PBMs (CarelonRx, Express Scripts, etc.) but must apply HCA's preferred drug list and PA criteria

WA HCA prior-authorization is a 5-step process model (eligibility -> code-requires-PA check -> forms -> submit -> status). Medical-necessity criteria are embedded in per-program billing guides (/node/301) and the Expedited PA (EPA) inventory, NOT standalone per-service guideline PDFs as in MA. Discovered 2026-05-28 via headless harvest.

Last award: original_IMC_awards_2016-2020_rolled_out_regionally. Next due: deferred_paused_during_PHE_unwind_SME_VERIFY. Contracts extended through: unknown_SME_VERIFY.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

## 1. How WA requires PA Washington State's Medicaid program, known as Apple Health, requires prior authorization (PA) for various services and drugs to ensure medical necessity and appropriate utilization of resources. The process is governed by the Washington Healthcare Authority (HCA), which oversees different carve-outs and managed care organizations (MCOs). For pharmacy services, a hybrid single preferred drug list (PDL) model is in place where HCA's Apple Health Single PDL governs all MCOs and fee-for-service (FFS) uniformly. However, MCOs administer claims through their own PBMs like CarelonRx or Express Scripts but must adhere to HCA's PDL and PA criteria. Specific services requiring PA include orthognathic surgery related to sleep apnea for clients age 21 and older, certain outpatient rehabilitation services (CPT codes 97530-97532, 97540-97546), chiropractic services for clients age 20 and younger (CPT codes 98941-98943), and vision hardware for clients age 20 and younger. Additionally, birth doula services require documentation including use of ORG: 532 and service type: LE. ## 2. How WA publishes and reports PA Washington State's HCA publishes detailed billing guides and prior-authorization forms that outline the criteria and processes for obtaining PA. These documents are available on the HCA website, which includes specific billing guides for various services such as orthodontic services, prescription drug programs, outpatient rehabilitation, home health services, medical equipment supplies, and vision hardware. The 5-step process model for prior authorization in WA involves: 1. **Eligibility**: Determining if the service or drug requires PA. 2. **Code-requires-PA check**: Verifying if the specific CPT/HCPCS code necessitates PA based on billing guides and EPA inventory. 3. **Forms**: Completing necessary forms such as the Pharmacy Authorization (Form 13-835A) or General Info Authorization (Form 13-835). 4. **Submit**: Submitting the completed form through designated channels, which may include electronic submission via portals or paper-based processes. 5. **Status**: Checking the status of the PA request, typically available through provider portals or by contacting HCA directly. Monthly bulletins and annual reports provide updates on changes to PA requirements and processes. For example, the Annual Report on Medicaid Prior Authorization Modernization (January 1, 2024) outlines criteria for completing PA requests within specified timeframes and provides information on expedited requests. ## 3. WA's CMS-0057-F and PA-reform compliance posture Washington State is actively engaged in preparing for the implementation of CMS-0057-F, which mandates the use of Fast Healthcare Interoperability Resources (FHIR) standards for prior authorization processes. The state has taken a proactive stance by establishing the FHIR Prior Authorization Workgroup as directed by HB 1357. This workgroup is tasked with developing an interoperable roadmap to align with CMS's Jan 2027 effective date. Washington is also one of the public-posture leaders (WA and CO) on Medicaid CMS-0057-F readiness. Separately, **WA is one of the six states in the federal WISeR model** — CMS's "Wasteful and Inappropriate Service Reduction" Medicare prior-authorization demonstration (the six states are AZ, NJ, OH, OK, TX, WA; model went live January 5, 2026). WISeR is a Medicare-side PA pilot and is distinct from WA's Medicaid CMS-0057-F FHIR work; the original synthesis incorrectly expanded WISeR as a Washington electronic-reporting system, which is corrected here. ## 4. How WA runs its own program Washington State's Medicaid program is managed through a combination of fee-for-service and managed care models. The state has implemented carve-outs for behavioral health (BH), long-term services and supports (LTSS), and pharmacy services, each with specific governance structures. - **Behavioral Health Carve-Out**: Behavioral health services are carved in via integrated managed care contracts (IMCs). This means that BH services are included within the IMC framework but may have additional carve-in mechanisms for crisis services. - **Long-Term Services and Supports Carve-Out**: LTSS services are carved out to the state, meaning they are not part of the IMC structure. Instead, these services are managed directly by HCA or through separate contracts with providers. - **Pharmacy Carve-Out**: Pharmacy services follow a hybrid single PDL model where HCA's Apple Health Single PDL governs all MCOs and FFS uniformly. MCOs use their own PBMs but must comply with HCA's PDL and PA criteria. The state has also implemented the Medicaid Transformation Project 2.0 (MTP 2.0) through a Section 1115 waiver, which aims to improve health outcomes and reduce costs by integrating physical and behavioral health services, among other initiatives. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Unified PA Process**: The state has a consistent 5-step process for prior authorization across different service categories. - **Behavioral Health Integration**: Behavioral health services are integrated into the IMC framework but have additional carve-ins for crisis services. - **Pharmacy Governance**: A hybrid single PDL model ensures uniformity in pharmacy management while allowing MCOs to use their own PBMs. - **WISeR participation**: WA is a WISeR (Medicare PA model) state and a Medicaid CMS-0057-F public-posture leader — an unusually forward regulatory profile. ### What's Missing/Uncertain: - **Specific PA Criteria**: While billing guides and EPA inventories provide general criteria, specific PA requirements for many services are not detailed in the provided documents (e.g., ABA services, CBHS). - **Foster Care Program Details**: The Apple Health Core Connections (AHCC) program for foster care is mentioned but lacks detailed information on its PA processes. - **MCO Procurement Timeline**: The next procurement cycle for IMCs is deferred due to the COVID-19 public health emergency (PHE), and there is no published timeline for when it will resume. These gaps highlight areas where additional information would be beneficial for a more comprehensive understanding of Washington State's Medicaid prior authorization processes.