Washington's Health Care Authority requires the HCA 13-772 when a provider requests Apple Health fee-for-service authorization for hearing aids, either as a limitation extension or an exception to rule. A clinician meets it when a client's hearing aid request falls outside standard program limits. HCA reviews the current audiogram, the explanation of why authorization is needed and answers about the client's functional needs.
The audiologist or hearing aid provider completes the form, including clinic and billing provider details, ProviderOne client ID, ICD-10 diagnoses, procedure codes and the clinical justification.
Download the current version from the source each time; forms change without notice.
Hearing Aid Authorization Request
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Yes. When faxing, the HCA 13-772 must go with a typed and completed General Information for Authorization form, HCA 13-835, as its cover sheet. The 13-835 carries the program and service type codes, such as Org 508 for medical with service type HEA for hearing aids, along with the client and provider details.
The form asks you to check one and explain why the request is being submitted, for example that the service is not covered, so an exception to rule is requested, that a limitation extension is needed, or that the client does not meet program criteria. The clinical justification then supports that request.