Home care billing · WA
Home care billing in Washington
Short answer
Home care billing in Washington is fee-for-service through ProviderOne, not through the Apple Health plans. DSHS Home and Community Services assesses the client and authorizes the hours, the agency picks its own EVV system under the Provider Choice Model, and ProviderOne, the state's data aggregator, takes the claim only with the six required EVV data elements attached.
Claims need a transaction control number within 365 days of the date of service and can be adjusted for 24 months. A dedicated Remitwright biller builds social service claims against the authorization and keeps the EVV file layout right, serving Washington agencies remotely. Rules for other states are on the home care billing by state page.
Last reviewed by the Remitwright billing team. Editorial policy
Key facts for Washington home care billing
| Fact | In Washington | Source |
|---|---|---|
| Programs that pay | Community First Choice (1915(k) state plan option); COPES Waiver (0049.R09.00); New Freedom Waiver (0443.R04.00); Residential Support Waiver (1086.R02.00); Developmental Disabilities Administration waivers (Basic Plus 0409.R04.00, Core 0410.R04.00, Individual and Family Services 1186.R02.00, Children's Intensive In-Home Behavioral Support 40669.R03.00, Community Protection 0411.R04.00) | 2 |
| How it is delivered | Fee-for-service for long-term services and supports | 9 |
| EVV | Provider Choice Model | 1 |
| Medicare home health and hospice | National Government Services, Jurisdiction 6 | 13 |
Programs that pay for home care in Washington2
Community First Choice (1915(k) state plan option)
Washington's Medicaid state plan option under section 1915(k) of the Social Security Act, administered by the DSHS Home and Community Living Administration to give clients more service options to remain in community settings.
Eligibility for long-term services and supports, including CFC, requires both financial and functional criteria; DSHS's CFC page is cited below.
COPES Waiver (0049.R09.00)
Adult day programs, home-delivered meals, skilled nursing, specialized medical equipment and transportation for adults 65 and older and adults ages 18 to 64 with physical disabilities who meet a nursing facility level of care.
A waiver amendment effective January 1, 2025 removed the manual reduction of personal care service hours by 30 minutes for each hour of adult day care and added death doula as a provider type under client support training and wellness education (DSHS amendment notice, cited below).
New Freedom Waiver (0443.R04.00)
Personal assistance service, treatment and health maintenance supports, individual directed goods, services and supports, environmental and vehicle modifications, and training and educational supports, in a budget-based program where the participant directs the services.
Operating since 2005 in King and Pierce counties; the renewal CMS approved on September 24, 2024, effective January 1, 2025 through December 31, 2029, extended it to Spokane, Whitman, Stevens, Pend Oreille and Ferry counties (DSHS renewal notice, cited below).
Residential Support Waiver (1086.R02.00)
Adult day health, residential services, nursing care and specialized medical equipment for adults 65 and older and adults ages 18 to 64 with physical disabilities who meet a nursing facility level of care.
Developmental Disabilities Administration waivers (Basic Plus 0409.R04.00, Core 0410.R04.00, Individual and Family Services 1186.R02.00, Children's Intensive In-Home Behavioral Support 40669.R03.00, Community Protection 0411.R04.00)
Respite, skilled nursing, therapies, assistive technology, specialized habilitation, supported employment, community inclusion, residential habilitation and stabilization services.
For individuals with autism, intellectual disabilities or developmental disabilities who meet an ICF/IID level of care; the Children's Intensive In-Home Behavioral Support waiver serves ages 8 to 20 and Community Protection serves adults 18 and older.
How the program is delivered
Fee-for-service for long-term services and supports. CMS's 2024 state tables list no MLTSS program for Washington: the Apple Health full-benefit plans (Fully Integrated Managed Care, region-specific under 1932(a) since April 1, 2016, with Amerigroup, Coordinated Care of Washington, Community Health Plan of Washington, Molina Healthcare of Washington and UnitedHealthcare) carry medical and behavioral health benefits, while in-home personal care, respite and the waivers are authorized by DSHS and paid through ProviderOne.9 ProviderOne is the state's data aggregator and receives claims from home care agencies and from Consumer Direct of Washington (CDWA), the Consumer Directed Employer of the state's 46,000 individual providers who deliver in-home personal care and respite (DSHS EVV and Consumer Directed Employer pages, cited below). Home health agencies billing ProviderOne follow HCA's home health EVV requirements.
Electronic visit verification
Provider Choice Model: providers select their own EVV systems, and ProviderOne is Washington's data aggregator, receiving claims from home care agencies and CDWA with all required EVV data elements according to the state file layout.1 The six elements are the type of service performed, the individual receiving the service, the date, the location, the individual providing the service, and the time the service begins and ends. Individual providers employed by the Consumer Directed Employer who live with their client are not required to use EVV, but every caregiving employee of a home care agency must use EVV for each shift worked. The federal mandate under the 21st Century Cures Act had implementation by January 1, 2021.
Services under EVV1
- Medicaid-funded in-home personal care
- In-home respite
- Home health care services, with home health agencies billing ProviderOne under HCA's home health EVV requirements
Authorizations
Through DSHS, not a payer portal. Local Home and Community Services offices provide the assessments, case management and the connection to long-term care services.7 A client qualifies for LTSS, including Community First Choice, only by meeting both financial and functional criteria (CFC page, cited below). Clients of the Consumer Directed Employer remain the managing employer who selects, schedules, supervises and dismisses their individual providers, while service hours continue to come from the existing assessment process (Consumer Directed Employer page, cited below). New Freedom runs on a participant budget instead of agency hours. In ProviderOne an authorization on its own does not get a claim paid: client eligibility, claim timeliness and third-party rules still apply at adjudication (ProviderOne billing guide, cited below).
Where the claims go
Claims go to ProviderOne for a transaction control number within 365 days of the date of service, or of a final fair hearing decision, a court order or HCA's delayed certification of eligibility, and a timely initial claim may be resubmitted, modified or adjusted for 24 months from the date of service; Medicare crossover claims are due within six months of the Medicare processing date.8 ProviderOne tags social service claims apart from medical claims: direct data entry social service claims, non-HIPAA social service batch submissions including templates, and social service repetitive, client payment, adjustment or void claims each carry their own claim medium indicator, and 'social services' is its own claim type. Retroactive Apple Health coverage earns one year from the date of the eligibility award. Home care agencies and CDWA send the EVV data elements with each claim under the state file layout (EVV page, cited above).
Medicare home health and hospice in Washington
National Government Services, the A/B MAC for Jurisdiction 6, processes Medicare home health and hospice claims for Washington along with Alaska, Arizona, California, Hawaii, Idaho, Michigan, Minnesota, Nevada, New Jersey, New York, Oregon, Wisconsin and the Pacific and Caribbean territories.13 Home health agencies hold an in-home services license from the Washington State Department of Health, must pass the initial survey before the license issues, and state licensure is a requirement for federal certification; a Medicare applicant also needs Certificate of Need approval before applying for Medicare certification and then files form 855A (DOH home health license requirements, cited below). Home care agencies are licensed by DOH too: the In-Home Services Orientation Class certificate must be on file before an application is processed, and an application not completed within nine months may be closed with no fee refund (DOH home care license requirements, cited below).
Common rejections in Washington, and the fix
Agency claim missing one of the six EVV data elements
The fixProviderOne receives home care agency claims with all required EVV data elements according to the file layout resources, and every agency caregiving employee must use EVV for each shift. The biller validates each claim line against the layout, including location and the individual who provided the service, before submission.
Claim submitted more than 365 days after the date of service
The fixThe initial claim needs a transaction control number within 365 days of the service date, with later start dates only for a fair hearing decision, a court order, delayed eligibility certification or a retroactive coverage award. The biller files against the service date and keeps the exception documentation with the claim when one applies.
Social service claim entered under the wrong claim type
The fixProviderOne gives social service claims their own claim type and medium indicators (direct data entry, template batch, repetitive and adjustment or void). The biller keeps in-home care authorizations on the social service side and home health on the medical side so each claim lands in the right adjudication path.
Live-in exemption applied to a home care agency employee
The fixOnly individual providers employed by the Consumer Directed Employer who live with their client are exempt from EVV; agency staff are not. The biller checks that every agency shift, live-in or not, carries an EVV record before it is billed.
Adjustment attempted after 24 months
The fixA timely initial claim can be resubmitted, modified or adjusted for 24 months from the date of service, and no longer. The biller works underpayments and corrections inside that window and flags anything approaching it on a separate calendar.
Medicare crossover claim filed late
The fixCrossover claims must be submitted initially within six months of the Medicare processing date, with resubmissions, voids or adjustments within two years of the from date of service. The biller tracks the Medicare processing date on each remittance and files the crossover from that date, not from the visit.
Home health billed before licensure or Medicare certification
The fixState licensure as a home health agency is a prerequisite for federal certification, a Medicare applicant needs Certificate of Need approval first, and the DOH survey must be passed before the license issues. The biller holds Medicare and Apple Health home health claims until the license and the 855A enrollment are both effective.
Remitwright serves Washington home care and home health agencies remotely, inside the agency software you already use, with a dedicated biller.
FAQ
Questions from Washington agencies
Can we keep our own EVV system in Washington?
Do live-in caregivers have to clock in under Washington EVV?
Is Washington in-home care paid through the Apple Health managed care plans or by DSHS?
How long do we have to bill ProviderOne, and can we fix a claim later?
What is the Consumer Directed Employer, and does it change what our agency bills?
How does New Freedom differ from COPES for our billing?
What licenses do we need before we bill for home health or home care in Washington, and who pays Medicare claims?
Which programs pay for home care in Washington?
Which services fall under EVV in Washington?
How are home care hours authorized in Washington?
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