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.
- Prior authorization requests.
- Backup documentation for a claim.
- Pharmacy claim/adjustment forms or rate requests.
- 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
Fax to: 1-866-668-1214
- 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)
- Electronic claim backup (ECB) attachments
- UB-04 attachments (when supporting documents are detached from original claim)
- CMS-1500 attachments (when supporting documents are detached from original claim)
- ADA 2006 dental attachments (when supporting documents are detached from original claim)
- Pharmacy claims attachments