ProviderOne Billing and Resource Guide
A complete guide for using ProviderOne.
The ProviderOne Billing and Resource Guide gives step-by-step instruction to help provider billing staff:
- Find client eligibility for services.
- Bill in a timely fashion.
- Receive accurate payments for covered services.
The guide is intended to:
- Strengthen the current instructions that apply to nearly all types of providers.
- Respond to provider requests for more step-by-step reference materials for ProviderOne.
All Apple Health (Medicaid) providers (excluding Tribal billing offices): Effective October 1, 2016, the Health Care Authority (HCA) will accept only electronic claims for Apple Health (Medicaid) services, except under very limited circumstances. We are making this change to improve efficiency in processing claims.
Criteria for exemption
Providers may seek approval to submit paper claims if they are in a temporary or long-term situation outside of their control that precludes submission of claims electronically. Examples of these unusual circumstances may include but are not limited to:
- HCA notifies provider in writing that paper claims will be accepted due to ProviderOne system issues precluding acceptance of electronic claims.
- The provider can demonstrate that the information needed for adjudication of an Apple Health (Medicaid) claim cannot be submitted electronically using the claim formats required under the ProviderOne Billing and Resource Guide.
- The provider is experiencing a disruption in their electricity or communication connection that is outside of his or her control and is expected to last longer than two days. This exception applies only while electricity or electronic communication is disrupted.
- Providers that have not submitted any electronic claims within the past state fiscal year (July 1, 2015 to June 30, 2016).
Providers who wish to ask for an exemption from submitting claims electronically may do so using the request a waiver form.
If you need further information regarding this notice, please review the Elimination of Paper Claims frequently asked questions (FAQ).
The appendixes below are included in the complete guide. They are presented here for your convenience.
Appendix C - Managed care organizations (MCOs)
Appendix D - Casualty claims and health insurance claims
Appendix E - Benefit services packages
Appendix G - How to check status of an authorization
Appendix H - Cover sheets for backup documentation
Appendix I - Completing the CMS-1500 claim form
Appendix J - Completing the UB-04 claim form
Appendix K - Completing the 2012 ADA dental claim form
Appendix L - Taxonomy and ProviderOne
Appendix M - Medicare crossover claim payment methodology
Appendix N - Use the IVR to check claim status
Appendix O - Use the IVR to check warrants
Use the provider billing guides and rates and fee schedules as companions to the billing and resource guide. You will use these regularly as you submit your claims.
- Professional rates, fee schedules, and billing guides
- Hospital rates, fee schedules, and billing guides