Document submission cover sheets

Use the following barcoded cover sheets to submit backup documentation by fax or hard copy. These allow ProviderOne to scan and update the current record with new information.

Types of documentation

  1. Prior authorization requests.
  2. Backup documentation for a claim.
  3. Pharmacy claim/adjustment forms or rate requests.
  4. Provider Enrollment information updates.

Send your back-up documentation with the barcode cover sheet as the first page of the packet to:

Heath Care Authority
RE: Cover sheets and back-up documentation
PO Box 45535
Olympia, WA 98504-5535

- Or-

Fax to: 1-866-668-1214

Prior authorization request

Note: The barcode cover sheet is used to include additional justifying information after the initial request is submitted.

For initial requests use the forms below:

Claims

Provider