Are you new to Washington Apple Health (Medicaid)? Wondering how to get prior authorization (PA) to provide a service? Or what you need to submit a claim?
Whether you're a hospital biller or individual provider, these steps will get you started.
Step one: Before you begin
Understand the provider process
As an Apple Health provider, your process looks something like this:
- Determine if your client is eligible for services or has a primary payer.
- Meet with your patient or client to determine what services are needed.
- Request prior authorization (PA) for those services—if required—from HCA.
- Perform the service for your patient or client.
- Submit a claim to HCA for payment for those services.
Make sure you have a ProviderOne profile
ProviderOne is the online billing and claims system you use for submitting your claims.
A ProviderOne profile (user account) is setup for you by either your organization's system administrator or ProviderOne Security (if you are the system administrator) when you complete your Apple Health enrollment.
I do not have a profile
- If your organization is new to ProviderOne, you must establish a system administrator. The system administrator will create all profiles for your organization. To create a system administrator profile, contact ProviderOne Security for assistance.
- If you are a user who will be submitting claims for your organization and do not have a ProviderOne profile, contact your organization's system administrator.
Access the ProviderOne Billing and Resource Guide
The ProviderOne Billing and Resource Guide gets you started using ProviderOne. This is a general guide that:
- Helps you determine the eligibility of a client.
- Explains the prior authorization (PA) process.
- Walks you through the process of submitting claims through direct data entry (DDE) using the provider portal.
Step two: Determine if you need a (PA) for services
Some services require prior authorization (PA) before you can provide the service. To determine if a PA is required and learn how to submit a PA to the Health Care Authority (HCA), visit our Prior authorization (PA) page for step-by-step instructions.
Step three: Complete your claim
Once you've provided services to your client, log into ProviderOne and complete your claim.
Tools to help you file a claim
Review the ProviderOne Billing and Resource Guide
Access specific fee schedules and billing guides
Utilize the rate information and billing guides available for specific programs:
Submit backup documentation
Use the document submission cover sheets to submit your backup, if necessary.