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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.
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