Wash. HCA Hospice Services Billing Guide, How do I request prior authorization (PA) for a noncovered service?

Providers may request PA for HCA to pay for a noncovered medical service or

related equipment. This is called an exception to rule (ETR). HCA cannot approve

an ETR if the exception violates state or federal law or federal regulation.

Note: Authorization does not guarantee payment. HCA’s

authorization process applies only to medically necessary

covered health care services and is subject to client eligibility and

program limitations. Not all categories of eligibility receive all

health care services. Example: Therapies are not covered under

the Family Planning Only Program. All covered health care

services are subject to retrospective utilization review to

determine if the services provided were medically necessary and

at the appropriate level of care. Requests for non-covered

services are reviewed under the exception to rule policy. See

WAC 182-501-0160.

For HCA to consider the request, ETR sufficient client-specific information, and

documentation must be submitted to HCA to determine if:

• The client’s clinical condition is so different from the majority that there is no

equally effective, less costly covered service or equipment that meets the

client’s need(s).

• The requested service or equipment will result in lower overall costs of care

for the client.

Note: For more details, see Resources Available.

HCA evaluates and considers ETR requests on a case-by-case basis according to

the information and documentation submitted by the provider. Within 15

business days of HCA’s receipt of the request, HCA notifies the provider and the

client, in writing, of HCA’s decision to grant or deny the ETR.

Note: Clients do not have a right to an administrative hearing on

ETR decisions.