DSHS Prior Authorization Guidelines

Dear Patient Name,
We received a referral regarding your candidacy for weight loss surgery. This letter contains
useful information necessary to proceed with bariatric surgery at the University of Washington
Medical Center.
If you have medical coverage through any program with Washington Medicaid (Apple Health),
including any managed care plan, all services involved in the bariatric surgery program
REQUIRE PRIOR AUTHORIZATION. Current managed care organizations are Molina,
CHPW, Amerigroup, United Health Care and Coordinated Care. The requirements for the
bariatric surgery program are set by state law (WAC) and the University of Washington is
required to follow them. If you start the program before receiving approval, the services will
not be paid for.
Please read through the individual steps/requirements/criteria below. You can also find
information at the State of Washington website:
http://apps.leg.wa.gov/wac/default.aspx?cite=182-531-1600.
Stage 1 (Preliminary Approval)
To qualify for the bariatric surgery program the following requirements must be met. If you do
not meet the requirements, you do not qualify for bariatric surgery under Medicaid rules and
Washington Medicaid (Apple Health) will not pay for this type of treatment.




Age -You must be between the ages of 18 and 59.
Body Mass Index (BMI) - You MUST have a BMI equal to or greater than 35.
(This number is determined by your primary care provider or by using standardized
BMI calculators that can be found on the internet.)
Medical conditions/Comorbidities – You must have ONE of the following
conditions:
o Diabetes Mellitus and/or;
o Degenerative Joint Disease of a major weight-bearing joint(s), such as knees or
hips, and you need joint replacement surgery immediately as soon as weight loss
is achieved.
o Other rare co-morbid conditions (such as pseudo tumor cerebri) in which there
is medical evidence that bariatric surgery is medically necessary and the benefits
of bariatric surgery outweigh the risk of surgical mortality.
You must NOT have multiple sclerosis (MS), which increases risk of mortality.
While there are a number of other medical conditions that are often a result of obesity, they do
not qualify for Washington Medicaid (Apple Health) approval. In the case that your condition
does not satisfy the requirements, we recommend you continue to explore other options with
your primary care provider (PCP) to find a non-surgical weight loss solution. Those who
University of Washington Medical Center
1959 NE Pacific St. Box 356165, Seattle, WA 98195
Page: 1
believe they meet the above criteria should contact their PCP who will request prior
authorization for Stage 2 of the process. You and your PCP must be willing to work together
over the next year to help you meet the requirements of Stage 2.
St Stage 2 (Pre-Surgery Stage)
You and your PCP must submit a completed the HCA/Medicaid applications for Stage 2 and
fax your medical records for review. The Washington Medicaid phone number is 360-7251584. The Medicaid fax number is 866-668-1214.
The forms your PCP needs can be found at:
 http://www.dshs.wa.gov/pdf/ms/forms/13_785.pdf
 http://www.dshs.wa.gov/pdf/ms/forms/13_835.pdf (must be first page of your fax)
Additional information you may need:
 UWMC NPI Number: 1023041159
 All forms must be TYPED, Not hand written
OR go to the UW Medical Center Web site. www.uwmedicine.org/weightloss. Forms are
under the Referring Provider Section.
Medicaid will review your request. You and your PCP will receive an official letter from
Medicaid with the approval or denial of your request.
If you are approved for stage 2, you will receive an approval letter. When/if you receive a
letter of approval, READ IT CAREFULLY! You and your You and PCP will need to complete
each of the requirements including keeping a record of when you complete each requirement.
Stage 2 of the Bariatric Surgery Program consists of evaluations and a supervised weight loss
to prepare you to make lasting changes in nutrition and behavior needed for this surgery to
succeed. Successful completion of the Stage 2 requirements will improve your health prior to
surgery and encourage the lifestyle changes you will follow for the rest of your life.
During the first 6 months of Stage 2 you will be required to:
 meet with your health care provider once a month to review your progress;
 meet with a dietician for counseling twice a month for at least 6 months (your provider
will give you a referral) ;
 lose at least 5% of your body weight based on a documented weight at a recent medical
in a 6-month period of time. You must maintain your weight loss until the time of
surgery;
 keep a journal of active participation in the medically structured weight loss regimen.
After 2 months into the 6 month supervised weight loss process your PCP can refer you to
UWMC, Center for Bariatric Surgery to enter the patient in the Bariatric program and continue
both programs simultaneously. The phone number is 206-598-2274; Fax 206-598-6705.
We will need the following items: Referral from your Primary Care provider, clinic notes
outlining current co-morbidities and weight loss attempts and the Stage 2 authorization letter
University of Washington Medical Center
1959 NE Pacific St. Box 356165, Seattle, WA 98195
Page: 2
from Washington Medicaid (Apple Health). We will contact you to set up the following
appointments for the final steps leading to surgery:
Bariatric Seminar – You will be scheduled to come for a required Bariatric educational
seminar.
Surgical Evaluation – After the seminar you will be scheduled for a consultation with a
surgeon who will evaluate you for the actual surgical procedure.
Psychosocial Evaluation – Scheduled at the University of Washington Medical Center with a
licensed psychiatrist or social worker.
Important! Keep your approval letter and complete the checklist you were sent. You and
your PCP must keep a record that the requirements have be met. The completed provider or
client checklist must be presented to the UW staff before Stage 3 will be requested. A copy of
your journal of active participation may be requested as part of the Stage 3 authorization
request.
 You must continue your regular visits with a dietitian and Primary Care Provider to
fulfill the Washington Medicaid (Apple Health), requirements while enrolled in our
program.
 You must maintain your weight loss till the time of surgery.
 You must be non-smoking for two months prior to starting our program
Stage 3 (Authorization for Surgery)
Following the process above, the Bariatric Team at UWMC will complete the necessary steps
for approval and scheduling for surgery. This process involves submitting all of the stage 2
records to Washington Medicaid (Apple Health), for final review. Once Washington Medicaid
(Apple Health), has made a determination, you will receive an official letter informing you of
your approval or denial for Stage 3. If approved, you will need to immediately fax the UW
Bariatric Team a copy of this approval letter to 206-598-6705. Once we receive a copy of this
letter we can schedule your surgery.
We hope that these guidelines clearly explain the process for you to obtain approval for
bariatric surgery. If you have additional question, please contact our clinic at 206-598-2274.
Sincerely,
UW Medical Center
Center for Bariatric Surgery
University of Washington Medical Center
1959 NE Pacific St. Box 356165, Seattle, WA 98195
Page: 3

Download Report