Effective Oct. 1, Medicaid providers will need to check the Washington State Prescription Monitoring Program (PMP) prior to prescribing any controlled substance (Schedule II through Schedule IV, not just opioids) to a patient enrolled in an Apple Health Managed Care plan or Fee-for-Service program. This includes patients with both Medicare and Medicaid, and those with third-party-liability where Apple Health is the secondary payer.

The provider PMP check must happen no more than 10 days before writing the prescription and must review the most recent 12-month period of prescription drug history of the patient, the number and type of controlled substances prescribed and filled, as well as who prescribed a controlled substance. Finally, the date and time of this review must be recorded in the patient’s record.

The task of checking the PMP may be delegated to anyone who has authorization to access the PMP, as long as the required information is relayed to the treating provider before the provider prescribes a controlled medication. In the case that the PMP is inaccessible or the provider is unable to access it, a “good faith” effort must be documented in the patient’s record, along with the reason or reasons the provider was unable to conduct the check and the provider’s intention to attempt the PMP check at a later date.

The Health Care Authority will monitor PMP checks by matching the date written on prescriptions in claims data with the PMP log data. A check inside of the 10-day appointment window will count as a qualified check and a check outside of that timeframe will count as an unqualified check. If there is no PMP review recorded for a prescription, the prescription will be documented as unchecked. The HCA may send educational letters to prescribers when less than 80% of a prescriber’s PMP checks are considered qualifying checks.

These changes will be reflected in the Oct. 1 Prescription Drug Program Billing Guide. For more information, please review the Health Care Authority’s FAQ on this new requirement and visit the HCA SUPPORT Act website.