HCA’s Clinical Guidelines and Coverage Limitations for Medication Assisted Treatment (MAT)

HCA Apple Health

Dear Provider: 

Effective for dates of service on and after October 1, 2015, all drugs prescribed as medication assisted treatments (MAT) to clients enrolled in an Apple Health Managed Care Organization (MCO) must be billed directly to the client’s plan.   

MCOs are required to cover MAT according to HCA published policies. Clients are not required to be enrolled in a DSHS treatment program in order to receive MAT, and there are no limitations on treatment duration if ongoing MAT is appropriate in meeting the client’s needs. Most MAT products will not require authorization, including buprenorphine/naloxone at doses up to 24mg per day. HCA’s Clinical Guidelines and Coverage Limitations for Medication Assisted Treatment (MAT) and drug specific criteria can be found on HCA’s Fee For Service (FFS) Drug Coverage Criteria page.  

If treatment continues for longer than six months, prescribers must complete form HCA 13-333  Medication Assisted Treatment Patient Status every six months and maintain it in the patient’s records for later audit and review by Health Care Authority. The requirement to complete and maintain the form HCA 13-333 Medication Assisted Treatment Patient Status applies to all MAT, including those not requiring prior authorization. The form can be found HCA’s Fee For Service (FFS) Drug Coverage Criteria page 

If you have any difficulty with claim payment or authorizations for Medication Assisted Treatment, please contact the patient’s MCO for assistance:

 

  • Apple Health Fee-for-Service                         1-800-562-3022
  • Amerigroup                                                     1-800-454-3730
  • Columbia United Providers                             1-800-315-7862
  • Community Health Plan of Washington          1-800-440-1561
  • Coordinated Care Health Plan                        1-877-644-4613
  • Molina Healthcare                                           1-800-869-7165
  • UnitedHealthcare                                             1-877-542-8997

 

For additional information please see the Prescription Drug Program Medicaid Provider Guide.