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.

Paperless billing at HCA

All Apple Health (Medicaid) providers: Effective October 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).

If your question is not answered using the FAQ, please contact the HCA Customer Service Center at 1-800-562-3022.

ProviderOne Billing and Resource Guide (complete guide)

Appendixes

The appendixes below are included in the complete guide. They are presented here for your convenience.

Appendix A - Use interactive voice response (IVR) to verify eligibility

Appendix B - Verifying eligibility using a magnetic card reader or MEV service

Appendix C - Managed care organizations (MCOs)

Appendix D - Casualty claims and health insurance claims

Appendix E - Benefit services packages

Appendix F - Instructions to fill out the General Information for Authorization Request form

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

Provider billing guides and fee schedules

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.

Note: We make updates as needed to reflect current policy, program updates, and ProviderOne system enhancements. For best results, bookmark this page so that you are always using the most up-to-date version of the guide.

Contact

Medical Assistance Customer Service Center (MACSC)
Online: Web form
Phone: 1-800-562-3022