Washington Telemedicine Laws: Licensure, Audio-Only, Parity

Washington is a full-license state with a short list of statutory exceptions, and one of the few states with genuine payment parity written into insurance law. The 2024 Uniform Telehealth Act, chapter 18.134 RCW, codified what the Medical Commission had long said — care happens where the patient is — and named exactly three situations in which an out-of-state license is enough. Carriers and Medicaid managed care plans must pay contracted providers for telemedicine at the in-person amount, though hospitals, hospital systems, telemedicine companies, and provider groups of eleven or more may negotiate a different rate, and audio-only rides on an "established relationship" rule the Legislature loosened in 2024.

Licensure: the Uniform Telehealth Act names the exceptions

RCW 18.134.060 fixes a telehealth service at the patient's location. Under RCW 18.134.050, an out-of-state practitioner may treat a Washington patient only if they hold a Washington license or are otherwise authorized here, "including through a multistate compact of which this state is a member," or if they hold a license in good standing elsewhere and the service takes one of three forms: a consultation with a practitioner who has a practitioner-patient relationship with the patient and remains responsible for diagnosing and treating the patient in Washington; a specialty assessment, diagnosis, or treatment recommendation that does not include providing treatment; or follow-up by a primary care practitioner, mental health practitioner, or recognized clinical specialist to maintain continuity of care with an established patient temporarily in Washington who received treatment in the state where the practitioner is located and licensed. The older consultation exemption in RCW 18.71.030(6) says much the same thing for physicians.

None of those covers a virtual practice marketing to Washington residents, and there is no telehealth registration of the Florida kind. The Act's enabling bill asked the state's telehealth collaborative to review a registration model and report by December 1, 2024; the collaborative has since wound down, and no registration has been enacted.

The practical route for physicians is the Interstate Medical Licensure Compact. Washington enacted membership through HB 1337 in 2017 (2017 c 195), and the Commission lists the compact as an expedited pathway alongside its standard application. Washington also participates in the Physical Therapy Compact. Washington is also a Nurse Licensure Compact state, issuing multistate licenses since January 2024, and a PSYPACT participating state; it has joined the Counseling Compact but is not yet issuing privileges.

Two more points. RCW 18.134.030 lets a practitioner-patient relationship form through telehealth but not "through email, instant messaging, text messaging, or fax," and RCW 18.134.040 bars a disciplining authority from setting a different standard because the care was remote. RCW 43.70.495 requires non-physician professionals who provide clinical services through telemedicine to complete a telemedicine training and retain a signed attestation; physicians are exempt. The Commission's 2021 telemedicine policy, which stated the patient-location rule, was taken up for rescission after the Act passed; verify with the Commission which guidance remains in force.

Prescribing: PMP queries, opioid limits and e-prescribing

Washington has no statute barring any drug schedule by telehealth, and RCW 18.134.030 lets a practitioner-patient relationship form through telehealth. RCW 18.134.040(1) applies the state's in-person standards and law, "including standards and law relating to prescribing medication," to telehealth, so a remote prescription carries the same duties as an office one. For physicians licensed under chapter 18.71 RCW, the duties are:

• PMP. WAC 246-919-985 requires a physician who prescribes Schedule II–V medications in Washington to register for the Prescription Monitoring Program or show assured access. Osteopathic physicians, physician assistants, and advanced registered nurse practitioners have their own PMP rules under their own boards (WAC 246-853-790, 246-918-935, and 246-840-4990). Before prescribing an opioid, or a benzodiazepine, barbiturate, sedative, carisoprodol, or nonbenzodiazepine hypnotic listed in WAC 246-919-970, the physician must ensure a PMP query is performed at least at the first refill or renewal of an opioid prescription for acute nonoperative or perioperative pain, at the transition from acute to subacute pain, and at the transition from subacute to chronic pain. For chronic pain the frequency is set by risk: at least quarterly for high-risk patients, semiannually for moderate-risk, and annually for low-risk. A query is also required immediately on identifying aberrant behavior in a chronic pain patient, and when giving episodic care to a patient the physician knows is receiving opioids for chronic pain. Where the electronic medical record builds PMP access into its workflow, a query is required for every prescription of an opioid or a WAC 246-919-970 medication. Queries can be delegated to an authorized designee, the duty is excused only when the PMP or record system cannot be reached because of a temporary technological or electrical failure, and pertinent concerns must be documented in the patient record. Nothing in the rule distinguishes a telehealth prescription from an office one, so telepsychiatry and pain practices should build the check into the visit.
• Opioid limits. The Medical Commission's rules set supply limits that can be exceeded only with documentation. For acute nonoperative pain, the physician "shall not prescribe beyond a seven-day supply without clinical documentation in the patient record to justify the need for such a quantity" (WAC 246-919-885(3)); for acute perioperative pain, the same documentation is required beyond a fourteen-day supply from discharge (WAC 246-919-890(3)). For chronic pain, prescribing at or above 120 milligrams morphine equivalent dose per day requires a documented consultation with a pain management specialist (WAC 246-919-930). The consultation may be an office visit with the specialist; a telephone, electronic, or in-person consultation between the specialist and the physician; an audio-visual evaluation the specialist conducts remotely while the patient is present with the physician or a licensed practitioner the physician or specialist designates; or other chronic pain evaluation services the Commission approves. A physician who has documented adherence to the chronic pain standards in WAC 246-919-905 through 246-919-925 need not consult when the patient is following a taper, when acute pain requires a temporary escalation with an expected return to the baseline dose or below, when the patient's pain and function are documented as stable on a nonescalating dose, or when the physician documents reasonable attempts to obtain a consultation and the circumstances justifying prescribing above 120 MED without one (WAC 246-919-935). Physicians who meet the pain-management qualifications in WAC 246-919-940 are exempt. So, for the first three months of care, is treatment of a new patient previously treated above 120 MED under an established written agreement, whose dose is stable and nonescalating, and who has a documented history of compliance and documented functional stability or pain control (WAC 246-919-955). A physician may not knowingly prescribe an opioid together with a benzodiazepine, barbiturate, sedative, carisoprodol, or nonbenzodiazepine hypnotic without documentation of medical decision making, and when a new prescription creates that combination because of another provider's prescription, the physician must consult the other prescriber to establish a patient care plan, except in emergency care (WAC 246-919-970). The opioid rules do not apply to cancer-related pain, sickle cell disease, palliative, hospice, or other end-of-life care, procedural medications, or patients admitted for more than 24 hours to listed hospitals, nursing facilities, and residential treatment facilities (WAC 246-919-851).
• State registration. Washington issues no separate state controlled-substance registration to practitioners licensed or registered in Washington: RCW 69.50.302(4) exempts them from Pharmacy Quality Assurance Commission registration unless the exemption is denied for a violation of the chapter. The exemption is written for Washington licensees; we found no provision addressing out-of-state practitioners serving under the RCW 18.134.050 exceptions, so confirm with the Pharmacy Commission before prescribing a controlled substance without a Washington license. PMP registration is the state step.
• E-prescribing. Since January 1, 2021, RCW 69.50.312 requires Schedule II–V controlled substance prescriptions, and refill authorizations for Schedules III–V, to be electronically communicated to the pharmacy. The exceptions cover veterinarians; patients of a long-term care facility or hospice program; a temporary technological or electronic failure; prescriptions intended to be filled outside Washington; a prescriber and pharmacist employed by the same entity or by entities under common ownership or control; drugs for which the FDA or DEA requires elements that cannot be sent electronically; compounded prescriptions; nonpatient-specific prescriptions under a standing order, protocol, collaborative drug therapy agreement, or public health emergency; drug research protocols; cases where the prescriber reasonably determines the patient could not obtain an electronic prescription in time and the delay would harm the patient's condition; and prescribers holding a Department of Health waiver, which lasts one year or less and is available for economic hardship, technological limits outside the prescriber's control, or other exceptional circumstances. Medicare Part D separately requires at least 70 percent of Part D Schedule II–V prescriptions to be electronic under 42 CFR 423.160, subject to exceptions and waivers.

The Commission opened a rewrite of the opioid chapter in 2025 (WSR 25-10-039) with workshops running through late 2026; the current text stands until a final rule is filed.

Federal law adds a separate layer for controlled substances. Under the temporary rule DEA and HHS published December 31, 2025 (90 FR 61301), which runs through December 31, 2026, a DEA-registered practitioner may prescribe Schedule II–V controlled substances after a real-time audio-video telemedicine encounter without a prior in-person evaluation, when the rule's other conditions are met; audio-only encounters qualify only for Schedule III–V narcotic medications approved by the FDA to treat opioid use disorder. See our guide to federal telehealth laws.

Consent: no general mandate, but audio-only billing needs it in advance

Washington has no telemedicine-specific informed-consent statute for video visits; general consent duties and each profession's standards apply. The consent the state does mandate is financial. If a provider intends to bill a patient or plan for an audio-only visit, RCW 48.43.735 and the Insurance Commissioner's rule, WAC 284-170-433, require patient consent before the service, documented, retained at least five years, and revocable prospectively. RCW 74.09.325 and 71.24.335 impose the same requirement on Medicaid managed care and behavioral health, and HCA wants it in the client record. Separately, RCW 18.134.070 bars billing a patient directly for telehealth a plan will not reimburse unless the patient consented in advance.

Medicaid: fee-schedule parity, audio-only with conditions, e-consults

Apple Health, run by the Health Care Authority, pays the distant-site professional service at the current fee schedule amount for the code — the same as in person — and RCW 74.09.325 requires managed care organizations to pay the in-person amount as well, with the same eleven-provider carve-out found in insurance law. Bill with place of service 02 or 10 and add modifier 95 when the distant site is nonfacility; GT survives only for critical access hospitals on the optional payment method. HCA ties telemedicine billing to Washington licensure or a compact Washington recognizes, and requires the provider's state location in the record.

Audio-only follows the statutory established-relationship test — an in-person or video visit within three years with the practitioner or same group, or a referral from a practitioner who had one — plus documented consent. It is billed with modifier 93 for physical health and Part I mental health codes or FQ for substance use disorder and Part II behavioral health codes; a mixed encounter counts as audio-only when half or more of it was audio. No originating-site facility fee (Q3014) is paid for audio-only, store-and-forward, the home, inpatient hospital, or skilled nursing settings. Effective January 1, 2025, HCA rebuilt store-and-forward around e-consults (CPT 99451 and 99452) and deleted the teledermatology section. Remote patient monitoring is not in the telemedicine guide; check the program-specific guide before billing it.

Private insurance: payment parity with a size carve-out

RCW 48.43.735 requires a carrier to reimburse a telemedicine service when the service is covered in person, medically necessary, an essential health benefit, and safely and effectively deliverable remotely. For plans issued or renewed on or after January 1, 2021, the carrier must pay "the same amount of compensation" it would pay in person — payment parity, not just coverage parity — except that hospitals, hospital systems, telemedicine companies, and provider groups of eleven or more may negotiate a different rate. Carriers may subject telemedicine to all terms and conditions of the plan, including utilization review, prior authorization, deductibles, copayments, and coinsurance that apply to a comparable in-person service, and the section does not require a carrier to reimburse a provider or originating site that is not a contracted provider under the plan (RCW 48.43.735(6), (7)(c); WAC 284-170-433(5), (11)(c)). Parity is owed to in-network providers, not as an out-of-network payment right. Store-and-forward is paid only for services listed in the provider's contract, and originating sites include the home. Audio-only has required an established relationship since January 1, 2023; SB 5821 (2024 c 215) stretched the look-back from two years to three. The test also requires that the provider have access to sufficient health records to ensure safe, effective, and appropriate care, and billing requires the advance consent described above. Under WAC 284-170-433(7), a carrier may not deny or reduce payment for a video visit solely because it shifted to audio-only for unanticipated reasons, though it need not pay for both an audio-visual and an audio-only encounter in that case. RCW 41.05.700 applies the same rules to public and school employee plans. Self-funded employer plans sit outside all of it — the reimbursement guide covers that split.

What to watch

Three items: whether the Legislature revives an out-of-state registration now that the collaborative's review has lapsed; the Commission's opioid-rule and chapter 246-919 rewrites, which could change PMP timing; and the federal side, where the DEA framework and Medicare's flexibilities decide what Washington's lack of an in-person prerequisite is worth — verify current status. Confirm current requirements with the Washington Medical Commission and the Health Care Authority before acting, and compare Washington with its neighbors in the national overview.