Frequently Asked Questions about ProviderOne

Below are some questions providers are asking about ProviderOne.

To get answers to your other questions, please call 1-800-562-3022 (after the short introduction, press 5 for Provider then option 1 for Social Services.)

• What is ProviderOne?

  ProviderOne is an online electronic billing system for providers delivering services to clients who are eligible for Medicaid.

• Why is this change happening?

  The Social Service Payment System began operation thirty years ago. The technology is outdated and does not allow providers to manage their claims. ProviderOne is a modern system that offers providers more features, like claims management and flexible payment options.

• Who will be paid in ProviderOne?

  Most affected providers are those contracted to provide services for clients of the DSHS Aging and Long-Term Support Administration or the Developmental Disabilities Administration, currently receive payment through the Social Services Payment System and receive a 1099 tax form. See the Get Ready page for more details on who will be paid through ProviderOne.

• What are the benefits of ProviderOne?
  • Improves customer service
  • Improves health service access and quality
  • Improves system editing and reduces payment errors
  • Makes system changes more efficient
  • Reduces costs - improve cost recovery
  • Reduces fraud
  • Reduces inappropriate dispensing of services, equipment and drugs to clients
  • Ensures Medicaid is the payer of last resort
  • Provides flexible and responsive reporting to facilitate better decision-making about the Medicaid program
  • Maximizes federal matching dollars

  Visit the Health Care Authority's ProviderOne Project Overview page for more information.

• When will I start receiving payment from ProviderOne?

  Billing Go-Live is scheduled for late 2014. Training for billing will be available about four weeks prior to Go-Live.

• I don't own a computer. How can I bill in ProviderOne?

  Your local library and local WorkSource office are two free resources available to you. Other options include friends or family. Many providers are choosing to hand off the billing to someone else. Once you have your login information you can create additional users who could handle your billing for you.

• Will Providers be able to phone in claims each month after ProviderOne goes live?

  No, once ProviderOne goes live, claims will not be via phone or paper invoice. All claims must be submitted electronically, online with ProviderOne.

• My computer does not have a Windows based system. Can I bill in ProviderOne using a Mac or other system?

  ProviderOne is designed for Windows-based Internet Explorer versions 7.0 or higher and Adobe Acrobat Reader 10.0 or higher. While some Mac users may attempt a workaround, it is unclear how successful  their claims and billing will be. Tests have only been performed using Windows based software.

  ProviderOne staff is unable to provide technical support to those using Macs or other software to interact with the ProviderOne system. The Health Care Authority does not recommend using Apple/Mac products, cannot guarantee their efficacy or security, and providers use them at their own risk.

• I have not received my login information yet. What should I do?

  Enrollment of providers is staggered. A few providers are receiving log in credentials in September. Many providers will not receive log in credentials until the end of October.
  The Health Care Authority will send you log in credentials when it is your turn to enroll. First, you will receive an alert that your login information is on its way. A few days after that you will receive your Domain #/Provider ID # and login ID, and then a third email with your password.

  Social service medical providers were invited to enroll earlier in 2014. These providers have additional steps to take before they are payable in ProviderOne.
• Our business already bills in ProviderOne. How will I receive my login information?

  Ask your business's current System Administrator to assign you as a user.

• How will ProviderOne change the way I bill?

  Your billing activities will be online rather than by phone or on a paper invoice. You will have the option to bill as frequently as weekly or less often if you choose. Billing will be done by date of service, so be sure to start tracking date of service now. You will also be able to adjust or correct your own billing, rather than having to ask a Social Service Case Manager to make corrections for you.

• What is staying the same?

  The Social Service Case Manager is still responsible for conducting assessments and authorizing services and your contacts for your contract and license or certification are remaining the same. Program rules and policies are not changing. Direct questions about rules and policies to your current DSHS contact.

• What can I do to make sure I receive all communications about ProviderOne?

  ProviderOne communications could come from WaHCA@public.govdelivery.com , noreply@hca.wa.gov, or a number of other DSHS or HCA email addresses. Please watch your junk or spam mail folders to make sure that your messages are going to your inbox. Your best bet is to add the Domains of @dshs.wa.gov and @hca.wa.gov to your safe senders lists – most email carriers have this option, but you may need to research your own email carrier to find out how. Nobody likes spam, but your ProviderOne emails will be very important to you!

• I am logged into ProviderOne. Why can't I access all the screens and see my authorizations?

  Your authorizations are still in SSPS. The screens in the Social Services billing area will be available after we "go live" with payment authorizations later this year.Take the time now to verify addresses and payment information so you are ready when authorizations transfer to ProviderOne.

• What are the different profiles that social service providers might have?

  There are two profiles for social service providers.

  • The Social Service Provider profile is used for billing and most functions in ProviderOne. This is the most common profile to assign to other users.
  • The System Administrator profile is only for adding or removing users and updating other profiles. Be cautious about giving others the System Administrator profile. Once another person has that profile, he or she could change your access. You cannot bill or submit claims with the System Administrator profile. Toggle out of the System Administrator profile to access different functions.

• Our System Administrator changed. What can I do to fix this?

  Email the Billing Assistance Team, they can verify your identity and make a request to the ProviderOne Security Desk on your behalf to get the information corrected.

• I receive my payment through an electronic funds transfer (EFT) now. Will that continue in ProviderOne?

  Yes, EFT information will be brought into ProviderOne from SSPS. If you receive EFT in SSPS, you will receive EFT in ProviderOne. You do not need to complete a new EFT application to continue to receive EFT. We do ask that you verify all of your information when you login to ProviderOne and take action if it needs to be updated. EFT is a dependable, secure, and convenient choice. It also results in savings to the State of Washington and all of its citizens.

• Will training be available?

  Yes, providers will be emailed links to training videos, how-to guides, and webinars directly. The information will also be posted on our website. Visit the Training tab for the latest training information.  

• I am a medical provider. Is there additional training available for me?

  Medical billing differs from social service billing. You can learn more about billing as a medical provider by following this link.

• I provide personal care and respite. Will I be paid in ProviderOne?

  Individual Providers will continue to be paid through SSPS until late 2015. Some providers are contracted as an Individual Provider and are contracted for other services. You may have services, other than personal care or respite, transitioning to ProviderOne. Email  IPCommunications@hca.wa.gov for more information.

Frequently Asked Questions from Durable Medical Equipment Providers

We have recently received questions from several Durable Medical Equipment providers regarding claims they have submitted for items requested via a social service authorization. What follows are answers to many of the questions. We are reviewing issues related to claims being denied for lack of Medicare documentation and additional guidance will be provided soon.

• Why did SSPS go away? Why did ProviderOne start being the payment system for social services?

  ProviderOne became the payment system for social services for several reasons, one of which was to be in compliance with Centers for Medicare and Medicaid Services (CMS) requirements for a single state agency to be responsible administering any Medicaid-funded program or service. The Health Care Authority (HCA) is Washington's Medicaid agency. This means all Medicaid funding must come through HCA's billing and payment system (ProviderOne) and HCA must administer or oversee the administration of all Medicaid programs and services (see 42 CFR 431.10).

• Do I have to have a contract with HCA in order to submit claims in ProviderOne?

  All medical providers, which include Durable Medical Equipment providers, must have a contract (known as the Core Provider Agreement (CPA)) with HCA. This contract governs the relationship between the state and the providers. The CPA's terms and conditions incorporate federal laws, rules and regulations, state law, HCA rules and regulations, and HCA program policies, Provider Notices, and Provider Guides.

• Do I have to follow the HCA billing procedures to submit a social service claim?

  Providers of medical services and items must submit a claim in accordance with HCA rules, policies, Provider Notices, and Provider Guides in effect at the time they provided the service or item. HCA does not assume responsibility for informing providers of national coding rules. Claims billed in conflict with national coding rules will be denied by HCA.

• Do I have to be Medicare enrolled in order to submit claims in ProviderOne?

  The provider must accept Medicare assignment for claims involving clients eligible for both Medicare and Medicaid before the department makes any payment. In order to achieve this, the provider must be Medicare enrolled (see WAC 182-502-0100).

• Do I have to accept the Medicaid State Plan rate?

  HCA pays for covered services and items on the basis of usual and customary charges or the maximum allowable fee established by the department, whichever is lower. This includes services and items which may be covered under certain circumstances (see WAC 182-502-0100). HCA pays for non-covered items and services authorized by DSHS at the rate established by DSHS policy or authorized by the social services case manager, whichever is lower.

• Who is responsible for verifying whether the client has medical assistance coverage for the dates of service?

  The provider is responsible for verifying whether a client has medical assistance coverage Medicare, Medicaid State Plan, or Managed Care) for the dates of service (see WAC 182-502-0100).

• I received a social service authorization. When I tried to claim for the item I provided, my claim was denied because Medicare would cover the payment. How do I get paid?

  If the item or service is covered by Medicare, and if the client is covered by Medicare, then payment from Medicare should be sought before any claim is submitted to ProviderOne (see WAC 182-502-0100 (4)). If Medicare denies the claim, then you may submit the claim to ProviderOne and attach the 'Medicare Denial Letter'.

• If I have to bill Medicare for many non-covered items, will I be flagged in any detrimental way by Medicare?

  You do not have to bill Medicare for non-covered items. You do not have to bill Medicare for covered items provided to non-Medicare covered clients.

• If I am denied by Medicare, will HCA pay for the item, instead of social services?

  If your claim is denied by Medicare, or is exempt due to a reason described in Question #8, then your claim will be reviewed for Medicaid State Plan coverage. If the claim is then denied by the Medicaid State Plan due to certain circumstances (such as exceeding the client's limit for that item in a five-year period), and a social services authorization for the item or service exists, then ProviderOne will use the social service authorization to adjudicate the claim.

• What if the item requested and provided was not something we would normally supply to a HCA client under the Medicaid State Plan benefit and so the reimbursement is less than what was agreed to in the quote- how will the system override this?

  If the item or service is covered by HCA, then the reimbursement cannot exceed the Medicaid State Plan rate. If the item or service is not covered by HCA, then the reimbursement cannot exceed the authorized amount or the billed amount, whichever is less.

• Could there just be a single code, like there was in SSPS, which would be used in ProviderOne without all these additional layers?

  We are required by CMS to use national codes (HCPC or CPT) which describe the service or item, when such codes are available. We are also required to ensure that DSHS waiver funding is only used after other resources (Medicare, Managed Care, Medicaid State Plan, etc.) are exhausted. Using the same authorization, claim, and payment system for social service and Medicaid State plan services ensure that these requirements are met

• My item or service was authorized using a 'blanket code', and the national code (HCPC or CPT) which describes what I actually provided is not contained within that blanket code. What do I do?

  One of two things happened: either the blanket code you were authorized was the wrong one; or the national code you provided is missing from the association to the blanket code. Please review the ProviderOne billing guide 'Blanket Code table'. If you were authorized the wrong blanket code, please contact the authorizing case manager to have the authorization corrected. If the national code cannot be found, please contact the BASS Unit and request that the configuration be corrected; this can usually be fixed within a business week.

• HCA/WACs state that while a client is enrolled in a Managed Care Organization (MCO) they will not fund non-covered DME. What process needs to be followed to have social services authorizations make it through the system?

  WAC 182-502-0100 states "The department does not pay on a fee-for-service basis for a service for a client who is enrolled in a managed care plan when the service is included in the plan's contract with the department." While it is true that neither HCA nor DSHS will pay for items covered by an MCO when provided to an MCO client, there are many items which are not covered by the MCO. These items, when allowed by policy, may be authorized through social services. We have reminded staff, and will shortly do so again, that DSHS is the payer of last resort and that social service authorizations should not be created when other funding sources may pay for the item.

• I am having difficulty with my claims being processed and receiving payment. What can I do?

  Please contact the BASS unit and request that a worker be assigned to help you.  Contact the BASS unit by:
  Phone: 800-562-3022 (after the short introduction, press 5 for Providers, then 1 for Social Services)
  Online Ticket: https://fortress.wa.gov/hca/p1contactus/SSProvider_WebForm
  Email: BASS@dshs.wa.gov