As a follow up to a recent Provider Alert from the Washington State Health Care Authority (agency): As of July 15, 2016, the agency will no longer accept the discontinued HCA 13-364 form for processing sterilization claims. Providers are required to use the federal consent form HHS-687 for sterilization procedures. In addition, the agency’s Sterilization Supplemental Provider Guide states that the agency will deny a claim received without the HHS-687 consent form, or with an incomplete or improperly completed HHS-687 consent form. Please refer to pages 14-15 of the guide for more information.

Community Health Plan of Washington (CHPW) pays claims in accordance with rules defined and published by HCA and other government agencies that conduct business with or regulate CHPW. While CHPW does need to comply with the agency’s requirement, we will allow our providers a grace period to begin using the HHS-687 consent form: Effective September 15, 2016 or when the agency begins denying claims that do not have the correct consent form, whichever occurs later, CHPW will also deny claims without a properly completed HHS-687 consent form.

CHPW has removed the discontinued Sterilization Consent Form and Sterilization Consent Form – Spanish from our website. We have also removed the Sterilization Client Statement Form, DSHS 13-364A, as it is no longer available in the Medicaid Forms list.

You can access these federal sterilization consent forms from our website:

Please begin using the federal forms as soon as possible.