Patient review and coordination

What is the Patient Review and Coordination Program? (PRC)

The Patient Review and Coordination (PRC) Program is a Medicaid health and safety program that coordinates care and ensures clients enrolled in PRC use services appropriately and in accordance with agency rules and policies. This program allows the agency to restrict clients to certain providers.

Many clients are seen by several different providers, have a high number of duplicative medications, use several different pharmacies, and have a high emergency room usage. Based on clinical and utilization findings, clients are placed in the PRC program for at least two years.

The PRC program may assign the client to a specific provider(s) chosen either by the client or assigned by the program. Clients can be assigned to one primary care provider (PCP), one pharmacy, one controlled substances prescriber or any combination of these providers. The assigned PCP will coordinate the client's health care needs, and monitor and educate clients about the appropriate use of services.

Why am I on this program?

The program has looked at your use of health care services, and our information and records show that you may have either overused or did not use health care services appropriately. Out of concern for your health and safety, this program is here to support coordination of the care you're getting.

How do I contact the PRC Program?

For clients who have Apple Health coverage without a managed care plan (also known as fee-for-service), contact the Health Care Authority (HCA) PRC program:

• Email HCA PRC or
• Call 1-800-562-3022 ext. 15606

If you are enrolled in an Apple Health (Medicaid) managed care plan (MCO), you will need to contact the MCO PRC Program for the plan you are enrolled with for assistance using the numbers below:

MCO PRC contacts

When can I change the MCO I am enrolled with?

Most clients enrolled in the PRC program can change MCOs after 12 months. You can also change MCOs if your current MCO is not available in the area you live in.

When can I change providers?

You're assigned to a provider for at least one year. After one year you can choose to change to a different provider. If you move out of the area or your provider moves out of the area or your provider can no longer manage your care, you can change your providers. To change a provider, you need to call your PRC program.

There are exceptions to the 12-month rule which are described in WAC. See WAC 182-501-0135 for additional information.

Do I need a referral for every provider?

Here's a list of services that do not need a referral:

• Behavioral Health Agency
• Dental services
• Substance Use Disorder (SUD) treatment facilities
• Emergency services
• Family planning agencies
• Health department
• Home health agencies
• Hospice
• Long term Care
• Medical transportation services (Emergent and Non-Emergent)
• Medical equipment
• Renal dialysis center
• Vision Care/optometrist

Can I get transportation to health care appointments?

Yes, you can get transportation to most health care appointments. If you need transportation to a health care appointment, you can call the transportation coordinator for your area and ask about the types of services offered. Visit Transportation Services (nonemergency) to locate a Transportation Coordinator.

What are my hearing rights?

You may ask for a hearing according to WAC 182-501-0135 if you disagree with the decision of your enrollment in the PRC program. The hearing must be requested within 90 days from the date of your initial placement letter. If you're enrolled in an Apple Health (Medicaid) managed care plan (Amerigroup of Washington, Coordinated Care of Washington, Community Health Plan of Washington, Molina Healthcare or UnitedHealth Care) you'll need to contact your plan for assistance.

• You have the right to have legal counsel or another person represent you at the hearing. You may get free legal counsel from a Legal Services Office.

• If you ask for a hearing within ten (10) calendar days of placement in this program, you won't be enrolled in the Patient Review and Coordination program until an order is issued placing you in the PRC program.

Visit the Office of Administrative Hearings website for more information about your hearing rights.

How do I ask for a hearing?

You have two options to request a hearing:

• Write to Office of Administrative Hearings, P.O. Box 42489, Olympia, Washington 98504-2489.
• Call 1-800-583-8271.

What other HCA and community resources are available?

View Apple Health HCA and community resources by choosing Free or low-cost health care at the top of any HCA webpage to browse medical, dental, and vision care services, find behavioral health support, or get resources to help others apply for Apple Health.