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Washington Apple Health (Medicaid)ProviderOne Billingand Resource GuideJune 2021

ProviderOne Billing and Resource GuideAbout this guideThis guide supersedes all previously published agency ProviderOne Billing and Resource Guides.What has changed?REASON FOR CHANGEUpdatePAGE NUMBERAppendix Epage 133SUBJECTACES coverage codesCHANGEAddition of new coverage categoryHCA accepts only electronic claims for Apple Health (Medicaid) services, except under limited circumstances. Providers mayseek approval to submit paper claims if they are in a temporary or long-term situation outside of their control that precludessubmission of claims electronically. Go to the ProviderOne Billing and Resource Guide webpage and go to “Paperless billing atHCA” for more information.Every effort has been made to ensure this guide’s accuracy. However, in the unlikely event of an actual or apparent conflict between this document and an agencyrule, the agency rule controls.2

ProviderOne Billing and Resource GuideTable of ContentsAbout this guide . 2What has changed? . 2Introduction . 7Who will benefit from this guide? . 7What does this guide cover?. 8Section 1: Apple Health (Medicaid) overview . 9What is Apple Health?. 9Who are Washington Apple Health clients? . 9How does Apple Health (Medicaid) compare to other payers? . 10How is Apple Health (Medicaid) different from Medicare? . 10How do I identify an Apple Health client? . 11Apple Health clients as consumers of healthcare services . 11Section 2: Provider enrollment . 12What are some of the benefits of being an Apple Health provider? . 12How do I become an Apple Health provider? . 12What is required to become an Apple Health (Medicaid) provider? . 12Who may enroll as an Apple Health provider? . 13Who must enroll as an Apple Health provider? . 13Understanding policies regarding provider enrollment . 13Understanding policies regarding documentation and paper claims . 14Which out-of-state bordering cities does Apple Health recognize? . 14Resources . 15Important contact information . 18Section 3: Eligibility, Benefit Service Packages, and service limits . 19Making sure you get paid for services covered through Washington Apple Health . 19Does the client have Apple Health (Medicaid) coverage? . 20Identifying the client’s primary payer and program type . 24Is the client enrolled in a managed care plan? . 25Is the client enrolled in integrated managed care? . 25Is the client enrolled in a Health Home program? . 26Is the client eligible for behavioral health services? . 27Is the client in a state-only program? . 27Is the client enrolled with Primary Care Case Management (PCCM)? . 27Is the client covered by Medicare? . 29Every effort has been made to ensure this guide’s accuracy. However, in the unlikely event of an actual or apparent conflict between this document and an agencyrule, the agency rule controls.3

ProviderOne Billing and Resource GuideDoes the client have commercial insurance, Medicare Part C or D, or military benefits? . 29Is the client restricted to specific providers? . 31Does the client receive services through a hospice agency? . 32Is the client a client of the Developmental Disabilities Administration (DDA)? . 32Is the client enrolled in the DOH Children with Special Health Care Needs (CSHCN) program? . 32Does the client have a Medicaid suspension due to incarceration or commitment to a state hospital? . 33Reviewing the Client’s Benefit Service Package. 34Client spenddown . 34Reviewing Foster Care clients’ medical records history . 36Does Apple Health cover the service and if so, is Prior Authorization (PA) required? . 40Looking up the procedure code in the appropriate fee schedule . 40Determining if the procedure is covered . 41Determining if there is a PA requirement . 41Claim payments – professional services . 42Claim payments – institutional services. 43Claim payments – inpatient hospital services. 43Provider preventable conditions (PPCs) . 43Have the client’s service limits been met? . 45Section 4: Submitting fee for service claims . 51Receive timely and accurate payments for covered services . 51Determining the claim submission method . 52Determining if a claim needs backup . 52Submitting new claims and backup . 54Direct Data Entry (DDE) in ProviderOne . 55Submitting backup documentation for a DDE claim . 62Resolving DDE claim submission errors . 67Entering commercial insurance information . 68Saving a DDE claim . 71Retrieving a saved claim. 72Submitting online batch claims . 73Entering Special Claim Indicators (SCI) . 74Submitting Medicare crossover claims . 75Overview of Medicare crossover process . 76Medicare Part B professional services . 77Medicare Part A institutional services . 78Every effort has been made to ensure this guide’s accuracy. However, in the unlikely event of an actual or apparent conflict between this document and an agencyrule, the agency rule controls.4

ProviderOne Billing and Resource GuideMedicare Advantage plans (Part C) . 80QMB – Medicare Only clients . 82Inquiring about the status of a claim . 84Timeliness . 86Adjusting, resubmitting, or voiding a claim . 86Claim templates . 93Submitting a template claim or batch of template claims. 98Section 5: The remittance advice . 101Understanding claim status . 101Retrieving the remittance advice . 102Adjustment types . 105Reviewing paid claims . 109Reviewing denied claims . 110Reviewing adjusted claims . 111Reviewing in process claims . 112Reviewing the EOB codes . 113Section 6: Requesting prior authorization . 114Completing the authorization intake process . 114Completing the DDE prior authorization intake process . 115Completing the General Information for Authorization form, HCA 13-835 . 115Checking the status of authorization requests . 117Sending in additional documentation if requested by HCA . 118Cover sheet tips . 119Examples of non-scannable cover sheets . 119For more information . 121APPENDIX A: Check client eligibility using the IVR. 122APPENDIX B: Verifying eligibility using a magnetic card reader or MEV service magnetic reader . 123APPENDIX C: Managed care organizations . 124APPENDIX D: Casualty and health insurance claims . 125APPENDIX E: Benefit Service Packages . 126ACES program codes . 129APPENDIX F: Completing the General Information for Authorization Request form, HCA 13-835. 133APPENDIX G: How to check status of an authorization . 134Checking authorization status using Interactive Voice Response (IVR) . 134Checking authorization status using ProviderOne . 135Every effort has been made to ensure this guide’s accuracy. However, in the unlikely event of an actual or apparent conflict between this document and an agencyrule, the agency rule controls.5

ProviderOne Billing and Resource GuideAPPENDIX H: Cover sheets for backup documentation. 137APPENDIX I: Taxonomy and ProviderOne . 138APPENDIX J: Medicare crossover claim payment methodology . 140Professional services . 140Institutional services . 141APPENDIX K: Checking claim status using the IVR . 142APPENDIX L: Checking warrants using the IVR . 144Every effort has been made to ensure this guide’s accuracy. However, in the unlikely event of an actual or apparent conflict between this document and an agencyrule, the agency rule controls.6

ProviderOne Billing and Resource GuideIntroductionThis guide provides a step-by-step resource to help providers and billing staff understand the processes of ensuringclients are eligible for services and to receive timely and accurate payments for covered services.DisclaimerA contract, known as the Core Provider Agreement (CPA), governs the relationship between HCA and Apple Health(Medicaid) providers. The CPA’s terms and conditions incorporate federal laws, rules and regulations, state law,agency rules and regulations, and agency program policies, provider notices, and provider guides, including thisguide. Providers must submit a claim in accordance with agency rules, policies, provider notices, and provider billingguides in effect for the date of service.HCA does not assume responsibility for informing providers of national coding rules. ProviderOne will deny claimsbilled in conflict with national coding rules. Consult the appropriate coding resources.Who will benefit from this guide?This guide serves as a resource for providers and billing staff whose duties are to: Maintain provider recordsSchedule client appointments or check in patients on the day they receive servicesSubmit fee for service (FFS) claims to HCAPost and reconcile paymentsThis guide assumes familiarity with standard medical billing practices and coding.NOTE: This guide does not include billing information for the pharmacy point-of-sale (POS) system. See thePharmacy information webpage for more information on the POS system or see the Prescription Drug Programprovider guide for more information.DSHS Social Service billers please refer to the ProviderOne for social services webpage for training resources.Every effort has been made to ensure this guide’s accuracy. However, in the unlikely event of an actual or apparent conflict between this document and an agencyrule, the agency rule controls.7

ProviderOne Billing and Resource GuideWhat does this guide cover?This guide consists of the following six sections:Section 1: Apple Health (Medicaid) overviewThis section explains the Apple Health (Medicaid) programs provided by HCA, how Apple Health compares to otherpayers, how Medicaid differs from Medicare, how to identify Apple Heal

ProviderOne Billing and Resource Guide Every effort has been made to ensure this guide’s accuracy. However, in the unlikely event of an actual or apparent conflict between this document and an agency rule, the agency rule controls.