Apple Health (Medicaid) Provider Alert

What changed?

As a reminder, effective January 1, 2020, payment for outpatient, inpatient, and ambulatory surgery center (ASC) facility fees for dental surgeries became the responsibility of the Apple Health client’s managed care organization (MCO).  This alert replaces the provider alert sent out on May 13, 2021 to include outpatient and ASC facility fees in addition to inpatient facility fees. 

What is the issue?

The utilization review/management of the service remains the responsibility of the Health Care Authority (HCA). This leaves a challenge for the MCOs to know if a service has been authorized since they do not have direct access to this information.

How do I avoid denials?

To avoid denials, when a prior authorization (PA) is required or when using an expedited prior authorization (EPA) as appropriate:

1. Provide a copy of HCA’s approval letter with your billing to the MCO.
2. Enter the PA number or EPA number on your billing to the MCO.

The client’s MCO may contact you to request the PA/EPA in advance.