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Document submission cover sheets
Use the following barcode cover sheets to submit backup documentation by fax or hard copy. These allow ProviderOne to scan and update the current record with new information.
On this page
- Prior authorization (PA) requests
- Backup documentation for a claim
- Pharmacy claim/adjustment forms or rate requests
Send your backup documentation with the barcode cover sheet as the first page of the packet to:
Heath Care Authority
RE: Cover sheets and backup documentation
PO Box 45535
Olympia, WA 98504-5535
Some services require authorization prior to treatment. For step-by-step instructions on submitting a PA request, please visit our Prior authorization (PA) webpage.
Commonly used PA forms
- Prior authorization pend forms (when supporting documents are submitted for a prior authorization request)
- Pharmacy prior authorization supporting documents
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:
- General information for authorization form (13-835), or
- Pharmacy information for authorization form (13-835A)
- Claim attachment (use when sending supporting documents to a non-pharmacy claim)
There is a known issue with some browsers when generating a bar code. If you are unable to generate a barcode using your current browser:
- Try using Internet Explorer (IE). (Available through June 15, 2022.)
- If you are unable to use IE to generate a barcode on the form:
- Enter the TCN or prior authorization number.
- Use the form as the fax cover sheet (i.e., the first page of the fax).
- For prior authorization (PA) pend forms (i.e., non pharmacy-related) no barcode is needed if you submit electronically.
- Sign into ProviderOne.
- Upload the documentation to the authorization.