Washington Medicaid Would Give You 7 Days, Not 30, to Answer a PA Records Request

Washington's Health Care Authority has proposed rewriting its fee-for-service prior authorization rule, WAC 182-501-0165, to meet the federal CMS-0057-F timeframes. Most of the changes speed HCA up. One speeds you up: when HCA asks for more information on a request, the provider's time to send it drops from thirty days to seven calendar days. The hearing and the written comment deadline are both Tuesday, October 27. HCA can adopt the rule from October 28.

What the proposal changes

From WSR 26-19-090, filed September 18:

• Standard PA decision: "in no case later than seven calendar days" after HCA receives the request. Today it's fifteen days.
• Your answer to a request for more information: "within seven calendar days of the agency's request," down from thirty. "If the provider fails to provide the additional information within seven calendar days, the agency will deny the requested service."
• HCA's decision once you answer: seven calendar days, replacing five business days.
• Expedited requests: a new track, decided within 72 hours.
• Denial notices: within seven calendar days, replacing ten business days.
• Exception to rule (WAC 182-501-0160): the same seven-day window for extra information on requests for noncovered services.

Who it reaches

The rule "applies to fee-for-service (FFS) requests" only. Apple Health managed care plans aren't governed by it. HCA's ABA billing guide says ABA needs prior authorization from HCA or the client's MCO, so the change reaches fee-for-service ABA authorizations, such as those for foster-care and American Indian/Alaska Native clients enrolled fee-for-service.

The federal clock behind this, and the first national denial data, are covered in our piece on the seven-day prior-auth clock. Washington's version moves the clock onto the provider as well.

The limits

It's a proposal. The notice sets no effective date, and HCA can change the text after comments.

What to do

• Owners with fee-for-service Apple Health clients, by 11:59 p.m. Tuesday: send a comment to arc@hca.wa.gov saying how long it really takes to assemble an ABA reauthorization packet: updated treatment plan, graphed progress, parent-training notes and the physician's order. A specific request, such as 14 days for the provider response, is more useful to HCA than an objection.
• Billing leads, now: treat any HCA "additional information" request as a same-day task with a five-day internal deadline. Write it into the intake checklist so a seven-day window can't run out over a weekend and a staff absence.
• Don't change your MCO workflows on the strength of this rule. They run on the plans' own timelines.