Chronic Opioid Attestation form—process update
Due to feedback and responses from the provider community, the Health Care Authority (HCA) updated the prescriber process for submitting the Chronic Opioid Attestation form (13-967) for Apple Health (Medicaid)
fee-for-service clients.
If you previously submitted an attestation form for
your patient and it was returned, follow the instructions below and
resubmit the request.
Prescribers
To request authorization for
your patient:
Pharmacy
billers
To submit a
request once an opioid prescription and attestation has been received:
- Bill
the opioid prescription first.
- Once
a claim is submitted, complete the agency’s Pharmacy Information Authorization form (13-835A) as you would for
any other authorization. This form must be typed and completed with all
required fields.
- As
supporting documentation to the Pharmacy Information Authorization form (13-835A),
attach the Chronic Opioid Attestation form (13-967) completed by the prescriber.
- Fax
both documents to HCA at: 866-668-1214. The Pharmacy Information
Authorization form (13-835A) must be the first document in the fax transmission.
If the patient is out of medication and requires opioids that day,
the pharmacy can use a one-time EA code 85000000542 for a known chronic opioid
user to dispense a 7-day supply while the attestation form is being completed.
If the pharmacy has already used the one-time EA code but an
authorization has not been approved due to attestation being previously
returned, an additional 7-day supply may be dispensed using the EA code
85000000542 while the attestation is being resubmitted.
For clients in Apple Health managed care plans
Please contact your patient’s plan to request an
authorization.
Phone numbers
and authorization fax numbers by plan:
Amerigroup
- Pharmacies: 1-844-367-6113
- Providers (authorizations
by phone): 1-800-454-3730
- Providers (authorizations
by fax): 1-800-359-5781
Apple Health Medicaid (fee-for-service)
- Pharmacies: 1-800-562-3022 extension: 15483
- Providers (authorizations
by phone): 1-800-562-3022 extension: 15483
- Providers (authorizations
by fax): 1-866-668-1214
Coordinated Care
- Pharmacies: 1-877-644-4613 Ext. 69622
- Providers (authorizations
by phone): 1-855-757-6565
- Providers (authorizations
by fax): 1-866-399-0929
Community Health Plan of Washington (CHPW)
- Pharmacies: 1-800-922-1557
- Providers (authorizations
by phone): 1-844-605-8168
- Providers (authorizations
by fax): 1-877-251-5896
Molina
- Pharmacies: 1- 800-213-5525 options 1,2,2
- Providers (authorizations
by phone): 1-800-213-5525 options 1,2,2
- Providers (authorizations
by fax): 1-800-869-7791
United Health Care
- Pharmacies: 1-888-306-3243
- Providers (authorizations
by phone): 1-800-310-6826
- Providers (authorizations
by fax): 1-866-940-7328
For more information and resources regarding HCA’s Apple Health (Medicaid) opioid policy, visit the agency’s Opioid webpage.
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