Requesting Prior Authorization
Contents
1. are black dots all over the image Please set your fax to photo quality image to improve the image quality a This is an example of a handwritten cover sheet The barcode is incomplete and ProviderOne will not be able to read this cover sheet and attach the submitted documentation to the electronic authorization record mo 020F 55 F 10 wll Not completing the barcode If providers do not press the enter key after typing the PA ID the barcode will not be created Using the Client ID instead of the PA ID Providers must enter the Prior Authorization number on the cover sheet Sending a cover sheet that is a poor quality image Barcodes must be readable by the scanner Sending an original authorization request form 13 835 when sending in additional information to attach to an existing authorization record 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 49 ProviderOne Billing and Resource Guide Appendix A Use IVR to Check Status of an Authorization 1 800 562 3022 Key 4 5 2 What will I hear The IVR will play the information only to the provider s identified on the authorization Search by the DSHS Services Card number and date of birth or by the authorization number If multiple authorization numbers are found narrow t2. for Out Patient CWN for Crowns PSM for Perio DEN for Dentures Scaling Maintenance DP for Denture Partial PTL for Partial ERSO for ERSO PA RBS for Rebases IP for In Patient RLNS for Relines ODC for Orthodontic MISC for Miscellaneous If you selected 502 Durable Medical Equipment DME for field 1 please select one of the following codes for this field AA for Ambulatory Aids OS for Orthopedic Shoe BB for Bath Bench OTC for Orthotics BEM for Bath Equipment misc OP for Ostomy Product BGS for Bone Growth Stimulator ODME for Other DME BP for Breast Pump C for Commode CG for Compression Garments CSC for Commode Shower Chair DTS for Diabetic Testing Supplies See Pharmacy Billing Instructions for POS Billing ERSO for ERSO PA FSFS for Floor Sitter Feeder Seat OTRR for Other Repairs PL for Patient Lifts PWH for Power Wheelch Home PWNEF for Power Wheelch PWR for Power Wheelch Repair PRS for Prone Standers PROS for Prosthetics 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 5 ProviderOne Billing and Resource Guide for Hospital Beds ae for Hospital Cribs IS for Incontinent Supplies MWH for Manual Wheelchair Home MWNE for Manual Wheelchair NF MWR for Manual Wheelchair Repair RE SC SBS for Specialty Beds Surfaces SGD for Speech Generatin
3. l3 ProviderOne Billing and Resource Guide Detailed Steps for Non Pharmacy Providers Note The quickest navigation is using the keys on your phone Dial 1 800 562 3022 the welcome message will play Stay on the line don t say anything the system is sensitive Or press 1 to go to the next step faster The system will then ask about an extension Stay on the line The main menu will play Press 5 or say Provider The provider menu will play Press 2 or say Authorization If this is the first inquiry of the call the system needs to collect your information The system will ask what type of provider you are Press 2 or say Medical If any other type of provider press 2 The system will ask for your NPI number Enter the NPI or say the NPI numbers individually For example if your number was 1023456 say one zero two etc Do not say ten twenty three Saying the letter O is not understood for a zero The system will then ask for the type of authorization Press 2 or say All Other The system will ask what you want to do next Press 2 or say Get Status Saying submit or pressing 1 will route the call out of the IVR The system will next ask how you want to search for the status Press 2 or say DSHS Services Card or 1f you have the authorization number press or say Authorization number The system will ask for the numbers Enter the number
4. maintains the POS code set To see the code set and definitions go to http www wpc edi com reference Place of Service Place of Service Name eed eot SemieName Indian Health Service Provider based Facility 8 Tribal 638 Provider based Facility 9 Prison Correctional Facility ____ 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 9 ProviderOne Billing and Resource Guide D1 Group A 15 Mobile Unit i 20 Urgent Care Facility fi 2 Inpatient Hospital i COO n Outpatient Hospital i a A Emergency Room Hospital i ed Ambulatory Surgical Center i Military Treatment Facility i C ee Ee p32 Nursing Facility M i e ooo Hospice o o a 7 p42 Ambulance AirorWater __ _ _ O ae Independent Clinic i gt 50 Federally Qualified Health Center FQHC Inpatient Psychiatric Facility a l Psychiatric Facility Partial Hospitalization 53 Community Mental Health Center i Intermediate Care Facility CF MR i Residential Substance Abuse Treatment Facility a Psychiatric Residential Treatment Center Substance Abuse Treatment eae 6O Mass Immunization Center 8 eerie Facility a Facility 65 End Stage Renal Disease Treatment Facility gt 71 PublicHealthClinic 7 2 Rural Health Clinic RHC 8I Indep
5. Resource Guide A contract known as the Core Provider Agreement governs the relationship between the Agency and Medical Assistance providers The Core Provider Agreement s terms and conditions incorporate federal laws rules and regulations state law Agency rules and regulations and Agency program policies numbered memoranda and billing instructions including this Guide Providers must submit a claim in accordance with the Agency rules policies numbered memoranda and billing instructions in effect at the time they provided the service 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 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 2 ProviderOne Billing and Resource Guide Requesting Prior Authorization The Key Steps 1 Complete Authorization Form 13 835 2 Submit Authorization Request to the Agency with required back up 3 Check the Status of a Request 4 Send in Additional Documentation if Requested by the Agency 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 3 ProviderOne Billing an
6. Transportation V for Vision VST for Vest 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 6 ProviderOne Billing and Resource Guide I for Infusion Parental Therapy VT for Vision Therapy MC for Medications MISC for Miscellaneous If you selected 509 Medical Nutrition for field 1 please select one of the following codes for this field EN for Enteral Nutrition MN for Medical Nutrition MISC for Miscellaneous If you selected 511 Outpt Proc Diag for field 1 please select one of the following codes for this field CCTA for Coronary CT OOS for Out of State Angiogram OTRS for Other Surgery CI for Cochlear Implants PSCN for PET Scan ERSO for ERSO PA O for Other GCK for Gamma Cyber S for Surgery Knife SCAN for Radiology GT for Genetic Testing MISC for Miscellaneous HO for Hyperbaric Oxygen MRI for MRI If you selected 513 Physical Medicine amp Rehabilitation PM amp R for field 1 please select one of the following codes for this field ERSO for ERSO PA PMR forPM andR MISC for Miscellaneous If you selected 514 Aging and Disability Services Administration ADSA for field 1 please select one of the following codes for this field PDN for Private Duty Nursing MISC for Miscellaneous If you selected 518 LTAC for field 1 ple
7. Washington State Health Care Medicaid ProviderOne Billing and Resource Guide Requesting Pnor Authonzation Complete the ProviderOne Authorization Intake Process This Guide Is Designed to Prepare You to Locate the General Information for Authorization form HCA 13 835 Fill out the Authorization Form with the Required Information Navigate ProviderOne Paper and Fax Intake Process Check on the Status of an Authorization Request Submit Additional Supporting Documentation with the Agency Cover Sheets When Needed ai 2 Note This chapter does not apply to pharmacy authorization Long Term Acute Care LTAC or Physical Medicine and Rehabilitation PM amp R admissions Why Requesting Prior Authorization Is an Important Activity Some Medicaid covered procedures require Prior Authorization If providers need to determine if the service requires authorization review the Client Eligibility Benefit Packages and Coverage Limits chapter of the ProviderOne Billing and Resource Guide This chapter will discuss how to submit an authorization request Submitting the request according to the Agency s guidelines will help expedite the authorization process Note Authorization for services does not guarantee payment Providers must meet administrative requirements e g client eligibility claim timelines third party insurance etc before the Agency pays for services ProviderOne Billing and
8. an actual or apparent conflict between this document and an Agency rule the Agency rule controls 13 ProviderOne Billing and Resource Guide When this option is chosen fax requests to the Agency and indicate the MEA in the NEA field box 18 on the PA Request Form There is an associated cost which will be explained by the MEA services Note The Agency is working on a process for using a similar mechanism for medical photos Using a cover sheet when faxing HCA form 13 835 to the Agency The first page of the fax must be the Agency s authorization request form Using automated outbound fax technology that has altered the size of the paper from 8 12x 11 Not having date stamp information up to date on your fax machine Not setting your fax machine to photo quality images Not putting x rays photos CDs in a separate envelope and not adding the required information on the outside of the inside envelope The requests get returned to the provider if they are not submitted correctly 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 14 ProviderOne Billing and Resource Guide Check the Status of a Request While waiting for the authorization request to process providers can check the status using the IVR or ProviderOne Two preferred methods to check an authorization
9. ase select one of the following codes for this field ERSO for ERSO PA LTAC for LTAC O for Other 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 7 ProviderOne Billing and Resource Guide If you selected 519 Respiratory for field 1 please select one of the following codes for this field CPAP for CPAP BiPAP OXY for Oxygen ERSO for ERSO PA SUP for Supplies NEB for Nebulizer VENT for Vent OXM for Oximeter O for Other 3 Name Required Enter the last name first name and middle initial of the client you are requesting authorization for Enter the client ID 9 numbers followed by WA For Prior Authorization PA requests when the client ID is unknown Client ID Required e g client eligibility pending Contact the Agency at 1 800 562 3022 and the appropriate extension of the Authorization Unit See contact section for further instructions A reference PA will be built with a placeholder client ID If the PA is approved once the client ID is known contact the Agency either by fax or phone with the Client ID The PA will be updated and you will be able to bill the services approved Living Arrangements Indicate where your patient resides such as home group home assisted living skilled nursing facility etc Reference Auth If requesting a change or e
10. d Resource Guide Complete Authorization Form 13 835 To begin the authorization process providers need to complete HCA Form 13 835 ProviderOne can begin processing the authorization request once the Agency receives this form filled out correctly Access the online authorization form 13 835 at http hrsa dshs wa gov mpforms shtml Forms are listed in numerical order Scroll down to find form 13 835 Providers can also find the form by using Control F and enter 13 835 in the find window Washington State _ _ Health Care Authority General Information for Authorization Serwice Type a Client Information Client 1D Reference Auth Provider Information Requesting NPI T Billing WPI 2 Requesting Fax Name as ae Referring NPI Referring Fax Service Start 13 Date 14 Service Request Information 20 Code 23 Units Days 24 3 Amount 25 Part 26 Tooth Qualifier Requested Requested DME Only or Quad Diagnosis Code Medical Information Place of service gt Diagnosis name 258 T 29 30 Comments http hrsa dshs wa 2owv mptfornns shtml Please Fax this form and any supporting documents to 1 866 668 1214 The matenal in this facsimile transmission is intended only for the use of the individual to who it is addressed and may contain infonnation that ts confidential privileged and exempt from disclosure under ap
11. endent Laboratory _ e Other Place of Service i 30 Comments Enter any free form information you consider necessary 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 10 ProviderOne Billing and Resource Guide A confirmation fax will be sent to the provider if the fax number can be identified by caller ID The receiving fax must recognize the number that the fax has been sent from Please do not use a cover sheet when faxing an authorization request The Authorization Request Form must be the first page of the fax If faxing multiple requests they must be faxed one at a time Refer to the program specific Medicaid Provider Guide for policy related questions Frequently asked questions helpful hints and instructions for completing the authorization request form for our most common service types can be located at http hrsa dshs wa gov Authorization This website contains examples of how to fill out the authorization form for specific provider types Hand writing the authorization request form Forms that are handwritten will be returned to providers Using NPI that is not on the Agency provider file Providers can confirm the are correct NPI is used by checking step 1 in the ProviderOne provider file Please see the ProviderOne Provider System User Manual for m
12. g Devices SF for Standing Frames STND for Standers TU for TENS Units US for Urinary Supplies WDCS for VAC Wound decubiti supplies MISC for Miscellaneous for Room Equipment for Shower Chairs If you selected 504 Home Health for field 1 please select one of the following codes for this field ERSO for ERSO PA HH for Home Health MISC for Miscellaneous T for Therapies PT OT ST If you selected 505 Hospice for field 1 please select one of the following codes for this field ERSO for ERSO PA HSPC_ for Hospice MISC for Miscellaneous If you selected 506 Inpatient Hospital for field 1 please select one of the following codes for this field BS for Bariatric Surgery ERSO for ERSO PA OOS for Out of State O for Other PAS for PAS If you selected 508 following codes for this field BSS2 for Bariatric Surgery Stage 2 BTX for Botox CIERP for Cochlear Implant Exterior Replacement Parts CR for Cardiac Rehab ERSO for ERSO PA HEA for Hearing Aids e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e RM for Readmission S for Surgery TNP for Transplants VNSS for Vagus Nerve Stimulator MISC for Miscellaneous Medical for field 1 please select one of the NP for Neuro Psych OOS for Out of State PSY for Psychotherapy SYN for Synagis T for Therapies PT OT ST TX for
13. han one client per fax Manually Processed into Imaging System SJUIOd MJIE SJUIOd 1NJ Ie Using old MMIS identifiers rather than ProviderOne identifiers SJUIOd 1NJ Ie eUse appropriate identifiers in fields SJUIOd 1N Ie Documents Rejected or Denied and Returned to Provider for Resubmission Prepare authorization package 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 12 ProviderOne Billing and Resource Guide By Fax Prior authorization requests can be faxed to 1 866 668 1214 If these forms are sent correctly they can be processed and loaded into ProviderOne with less human intervention Please follow these instructions when submitting a request Place form 13 835 as the first page that will come over the fax Please do not use your own cover sheets The first page that comes over the fax must be the HCA form 13 835 Set to size 8 1 2 x 11 and photo quality Fax each request to the Agency individually This means pausing between each fax If you fax multiple requests to the Agency at once ProviderOne will group them as a single request By Mail Prior Authorization requests can be mailed to Authorization Services Office PO Box 45535 Olympia WA 98504 5535 If sending x rays photos CDs or o
14. he search with an NDC or Service Code as well as an expected date of service The types of information available are Authorization Number Status date Status such as Approved In Review Denied Referred Pending Cancelled e Do not say the WA part of the Services Card e Say the numbers only for the Services Code skip the letters e Use your phone s mute option and key choices for the fastest navigation The ProviderOne IVR accepts voice responses or keypad entries indicated by brackets You can key ahead anytime Below is an overview of the prompts see next page for detailed step by step instructions i 1 800 562 3022 gt y Stay on the line or English 1 Spanish 2 ae PN Stay on the line or if an extension Dial Y Provider Services 5 D v Authorization 2 y Authentication if first inquiry Pharmacy 1 Medical or Dental 2 Enter NPI y Pharmacy 1 All Other 2 y Get Status 2 y Authorization Number 1 DSHS Services Card 2 Service Card numbers only gt Date of Birth gt 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 20 10 11 12
15. into this field Once the PA ID is keyed in the box a barcode will be generated by hitting the enter key This bar code allows our scanner to read the number similar to the grocery store when an item is scanned and the description and price appear on the screen of the register Then just print the completed form attach it to the supporting documentation and submit either via fax 1 866 668 1214 or mail PO Box 45535 Olympia WA 98504 5535 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 17 ProviderOne Billing and Resource Guide Here is an example of the PA cover sheet You can see the authorization number entered created a complete barcode ProviderOne PA Pend Forms Submission Cover Sheet Authorization Reference f i Please enter 9 digit numeric value a Instructions will mot appear on the printed coversheet INSTRUCTIONS Click ENTER on your keyboard after typing the number in above Cover Sheet Tips Hit the enter key after typing in the complete authorization number so the barcode is created arrow Cover sheets without completed barcodes will be returned Providers must submit a separate cover sheet for each authorization request when submitting back up documentation If faxing multiple documents each cover sheet and documentation set must be faxed indi
16. ls 8 ProviderOne Billing and Resource Guide S ICD 9 10 Diagnosis Code National Code Required Enter each service code of the item for which you are requesting authorization that correlates to the Code Qualifier entered When appropriate enter a modifier Units Days Requested Enter the number of units or days being requested for items that have a Units or required set allowable Refer to the program specific Medicaid Provider Guide for the appropriate unit day designation for the service code entered Amount Requested Units Enter the dollar amount being requested for those service codes that do or required not have a set allowable Refer to the program specific Medicaid Provider Guide and fee schedules for assistance Must be entered in dollars and cents with a decimal e g 400 should be entered as 400 00 Part DME only Enter the manufacturer part of the item requested Required for all codes requested Tooth or Quad Required Enter the tooth or quad number as listed below for dental requests QUAD 00 full mouth 01 upper arch 02 lower arch 26 10 upper right quadrant 20 upper left quadrant 30 lower left quadrant 40 lower right quadrant Tooth 1 32 A T AS TS and 51 82 Diagnosis Code Enter appropriate diagnosis code for condition Short description of the diagnosis Place of Service Enter the appropriate two digit place of service code CMS
17. ore information about checking the provider file Using NPI for servicing rendering treating provider in field instead of pay to provider 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 11 ProviderOne Billing and Resource Guide Submit Authorization Request to the Agency with Required Back up ProviderOne uses scanning technology that converts documents received via fax or paper into electronic files Make sure the form is submitted correctly to the Agency This will ensure your request can be processed and loaded into ProviderOne The technology works as outlined below ProviderOne Paper and Fax Intake Process X Rays Photos CDs and other Non Scannable Imaging System Documents FAX Auto Load into Imaging System identifies document DSHS Staff Work Request Loads into ProviderOne Images Document m gt e Missing identifiers e Missing 13 835 eSome returned to J e Missing cover client ID NPI eUsing incorrect provider PAPER sheet with taxonomy cover sheets e Missing back up barcode Poor image e Using screen documentation Typed eHandwritten quality form is prints of barcoded Documents Using your own unreadable cover sheets cover sheet on top e Using incorrect claim form More t
18. plicable law HIPAA Compliance Unless othenmise authonzed in writing by the patient protected health infonmnation will only be used to provide treatment to see insurance payment or to perform other specific health care operations HCA 13 835 8 4071 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 4 ProviderOne Billing and Resource Guide Type in the required fields before printing the form The table below describes what information should be placed in each field This table is also located online after the authorization form po ALL FIELDS MUST BE TYPED Org Required Enter the Number that Matches the Program Unit for the Request Service Type Required 2 Enter the Number that Matches the Program Unit for the Request 501 Dental 502 Durable Medical Equipment DME 504 Home Health 505 Hospice 506 Inpatient Hospital 508 Medical 509 Medical Nutrition 511 Outpt Proc Diag 513 Physical Medicine amp Rehabilitation PM amp R 514 Aging and Disability Services Administration ADSA 518 LTAC 519 Respiratory 521 Maternity Support Enter the letter s in all CAPS that represent the service type you are requesting If you selected 501 Dental for field 1 please select one of the following codes for this field ASC for ASC OUTP
19. s If using a services card do not say or try to enter WA a Enter the client s date of birth for example 03122010 If more than one authorization number is found enter the numbers of the service or procedure code Do not enter or say any letters Enter the anticipated or expected date of service If there are still multiple authorizations the system will transfer you to a staff person The system will play the authorization number the status and date of that status 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 4
20. status request include Using the IVR A provider will need the NPI used when preparing the authorization request form the ProviderOne Client ID and date of birth to use the IVR The IVR will provide the authorization number as well as the status information Please see Appendix A for details on using the IVR to check authorization status Using ProviderOne Select Provider Authorization Inquiry from the provider home page Search by one of the following options e Prior Authorization Number or e Provider NPI AND Client ID or e Provider NPI Client Last Name Client First Name AND Client Date of Birth PA Inquire o swbreit a Prior Authorization Inquiry compicte ome of the following cr tteria sets and click Subenit Prior Auvthortration Number or Provider fel AND Chent ID or Provider MPL Client Last Name Cent First Nance AND Client Date of Birth or additional information please contact owr Customer Service Center WA State DSHS Provider Relations 800 562 3022 Prior Authorization Number Provider NPI Client ID Client Last Name Client First Name Cliem Date of Birth 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 45 ProviderOne Billing and Resource Guide If the system finds an authorization request it will return the authorization request stat
21. ther non scannable items use the the following steps Place the items in a large envelope Attach the PA request form to the outside of the envelope Write on the outside of the envelope o Client name Client ProviderOne ID Your NPI Your name Sections the request is for MEAU Medical DME Durable Medical Equipment Dental or Ortho Then put the envelope in a larger envelope for mailing O O Oo Another option for submitting photos or x rays Dental Providers can submit dental photos or x rays for Prior Authorization by using the FastLook and FastAttach services provided by National Electronic Attachment Inc NEA Providers may register with NEA by visiting www nea fast com and entering FastW DSHS in the promotion code box Contact NEA at 800 782 5150 ext 2 with any questions When this option is chosen fax requests to the Agency and indicate the NEA in the NEA field on the PA Request Form There is an associated cost which will be explained by the NEA services Medical and DME Providers can also submit photos or x rays by using the FastLook and FastAttach services provided by Medical Electronic Attachment Inc MEA Providers may register with MEA by visiting http www mea fast com and entering FastWDSHS in the blue promotion code box Contact MEA at 1 888 329 9988 ext 2 with any questions Every effort has been made to ensure this guide s accuracy However in the unlikely event of
22. us PA Utilization Authorization 870000004 Authorization Status Approved Client ID 9999999WA Client Name Service Miscellaneous Organization PA DENTAL Request Date 12 23 2010 Last Updated Date 8 17 2011 Service Start Date 1 1 2011 Service End Date 9 30 2011 Requestor ID 8888688897 Requestor Name Place Holder PA Provider Line Servicing l x Modified provider Code CM modifiert ToothNum ToothSurf Quaa ToDate Request Request sra eara e Date Type Date Amount Units Amount Units A ID AY AY av AY AY AY YF AY AY k Y AY AY ay a v T K 08 17 2011 sssssssss7 Dental 01 01 2014 09 30 2011 99999 Approved Claim The following Authorization statuses may be returned Requested In Review Cancelled order to make a decision on the request Referred This means the request has been forwarded to a second level reviewer Approved Hold This means the request has been approved but additional information is necessary before the authorization will be released for billing Approved Denied This means the request has been partially approved and some services have been denied Rejected This means the request was returned to the provider as incomplete Approved This means the Agency has approved the request Denied This means the Agency has denied the request Calling the Medical Assistance Customer Service Center and waiting on hold to talk with an agent to check the status of an authori
23. vidually If providers fax multiple requests to the Agency at once ProviderOne will group them as a single request and all attachments will be attached to the electronic record for the authorization identified on the first cover sheet If mailing multiple sets of documentation can be mailed in a single envelope Providers can save the link to the cover sheets as a Favorite but always get them real time from our Web site to make sure they are using the correct version Do not save these to the computer desktop and re use them Do not use a cover sheet when submitting an original prior authorization form Ifa provider is creating multiple cover sheets on the same template be sure to click Clear Fields before entering the next authorization number 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 48 ProviderOne Billing and Resource Guide Examples of Non Scannable Cover Sheets It is important that our new scanning technology be able to read the barcode on the cover sheet If the fax quality is poor or the barcode is incomplete it cannot be scanned It is important to remember that these faxed documents are scanned directly into ProviderOne and are not touched by a staff worker Here is an example of a poor quality image The barcode below cannot be read because there
24. xtension to an existing authorization please indicate the number in this field Requesting NPI The 10 digit numeric number that has been assigned to the requesting Required provider by CMS Requesting Fax The fax number of the requesting provider Billing NPI Required The 10 digit numeric number that has been assigned to the billing provider by CMS The name of the billing servicing provider Referring NPI The 10 digit numeric number that has been assigned to the referring provider by CMS Referring Fax The fax number of the referring provider The date the service is planned to be started if known Description of service being A short description of the service you are requesting examples requested Required manual wheelchair eyeglasses hearing aid Serial NEA or Medical Enter the serial number of the equipment you are requesting repairs or Electronic Attachment modifications to or the NEA MEA to access the x rays for this MEA Required for all request DME repairs Code Qualifier Required Enter the letter corresponding to the code from below T CDT Proc Code 5 7 10 11 12 13 15 18 C CPT Proc Code D DRG P HCPCS Proc Code I ICD 9 10 Proc Code R Rev Code N NDC National Drug Code 20 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 contro
25. zation request Providers can check the status without having to talk with a customer service representative 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 16 ProviderOne Billing and Resource Guide Send in Additional Documentation if Requested by the Agency Once the Agency receives an authorization request it will proceed through the review process The Agency may request additional information in order to process the request If providers are mailing faxing supporting documentation or responding to a request from the Agency for additional information an Agency cover sheet printout is needed These cover sheets are needed when faxing or mailing in back up documentation to an existing authorization request Cover Sheets can be located at http hrsa dshs wa gov download document_submission_cover_sheets html There are many cover sheets that can be used for different tasks available on this website Providers will want to use the PA Pend Forms cover sheet for submitting additional information to an existing authorization request Providers will need to know the authorization number in order to use this cover sheet After selecting this form providers will be asked to fill in the PA ID This is the 9 digit authorization number to key in that box Do not copy and paste the PA number
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