HCA Clarifies Authorization and Payment Provisions for Monoclonal Antibodies and Ambulance Services

September 29, 2021

WSHA has been actively working with the Washington Health Care Authority (HCA) to identify and remedy issues impacting access to medical care during the COVID emergency. WSHA recommends hospitals share this information with appropriate staff.

  • In response to reports that some Medicaid managed care plans were requiring prior authorization for monoclonal antibody treatment, HCA issued a statement to the plans that prior authorization is not to be required for the service. Monoclonal antibody treatment is most effective if administered before the onset of major symptoms so prompt treatment is critical. HCA is in process of updating its clinical and billing policy and will provide additional clarification.
  • HCA also heard concerns from WSHA members regarding access to ambulance services. Ambulance capacity has been under extreme pressure during the state of emergency due to the volume of cases, including cases where patients need to be transported greater distances to receive care, resulting in shortages of ambulance services. HCA wants hospitals and ambulance providers to be aware that HCA is paying an enhanced Medicaid ambulance payment rate for patients with a COVID-19 diagnosis, as well as for non-Covid patients when needed to clear hospital capacity. This includes transfers from the hospital to an alternate care suite such as a skilled nursing facility. Ambulance providers should bill a “CR” modifier in these cases for HCA to pay the enhanced payment rate. As a reminder, HCA does not require prior authorization for in-state ground ambulance services.  More information is available on page 48 of the Ambulance Transportation Billing Guide and on the Ambulance Fee Schedule. (Andrew Busz, Andrewb@wsha.org).


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