Authorization of Secure Ambulance Transportation to/from Behavioral Health Services (HCA 42-0003) form revised

Washington State Health Care Authority sent this bulletin at 12/23/2019 01:23 PM PST

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Apple Health (Medicaid) Provider Alert

The Health Care Authority (HCA) has revised the voluntary services attestation section of the Authorization of Secure Ambulance Transportation to/from Behavioral Health Services (HCA 42-0003) form. Effective immediately, HCA no longer requires an assessment conducted by a designated crisis responder (DCR) to be performed for individuals seeking voluntary behavioral health (BH) services.

What does this mean for providers?

For the purposes of continuity of care, the HCA 42-0003 form has been revised as follows:

If an individual is assessed by an emergency department (ED) physician/attending physician, and is determined to meet the criteria for voluntary services, the physician would be the medical professional signing the voluntary attestation section of the form.
If an individual is assessed by an ED physician/attending physician, and is determined not to meet the criteria for voluntary services, the physician would contact a DCR to initiate the process for involuntary services pursuant to Chapter 71.05 and 71.34 RCW. The DCR would be the medical professional signing the DCR attestation section of the form.

Amended Form The revised HCA 42-0003 form can be found on the agency’s Forms and Publications website.

Who do I contact if I have questions?

For more information, contact Shauna James, Ambulance Program Manager.

About the Health Care Authority (HCA)

The Washington State Health Care Authority (HCA) is committed to whole-person care, integrating physical health and behavioral health services for better results and healthier residents.

HCA purchases health care for more than two million Washington residents through Apple Health (Medicaid), the Public Employees Benefits Board (PEBB) Program, and, beginning in 2020, the School Employees Benefits Board (SEBB) Program. As the largest health care purchaser in the state, we lead the effort to transform health care, helping ensure Washington residents have access to better health and better care at a lower cost.

Please do not reply directly to this message. For more information, visit the HCA website, where you'll also find contact information.

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Nondiscrimination

The Washington State Health Care Authority (HCA) complies with all applicable federal and Washington state civil rights laws and is committed to providing equal access to our services. Visit HCA’s website to view complete nondiscrimination statements.

Authorization of Secure Ambulance Transportation to/from Behavioral Health Services (HCA 42-0003) form revised

Apple Health (Medicaid) Provider Alert

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About the Health Care Authority (HCA)

Disclosure notice

Nondiscrimination