State · WA
Medical billing services in Washington
Short answer
Medical billing services in Washington run fee-for-service Apple Health claims through ProviderOne, where a claim needs a TCN within 365 days of the service and can be corrected for up to 24 months, while five Apple Health plans, each contracted as both managed care organization and prepaid inpatient health plan, serve 10 integrated managed care regions.
Commercial carriers must pay 95 percent of each month's clean claims within 30 days under WAC 284-170-431, and Apple Health telemedicine is billed on POS 02 or 10, with modifier 95 for a nonfacility site. A Remitwright dedicated biller works those rules, serving Washington practices remotely. Rules for other states are on the medical billing services by state page.
Last reviewed by the Remitwright billing team. Editorial policy
Billing in Washington: what's different
The rules below change how a claim is filed and paid in Washington. Each line links to the official page it was read from, and the date at the top of this page is when it was last checked.
| Fact | In Washington | Source |
|---|---|---|
| Medicaid program | Washington Apple Health (Medicaid)Washington State Health Care Authority (HCA) | 1 |
| Fee-for-service portal | ProviderOne | 1 |
| How Medicaid is delivered | Integrated managed care | 2 |
| Managed care plans | 5 plansCommunity Health Plan of Washington, Coordinated Care of Washington, Molina Healthcare of Washington, UnitedHealthcare Community Plan of Washington, Wellpoint Washington | 2 |
| Medicaid timely filing (fee-for-service) | 365 calendar days from the date of service | 4 |
| Prompt-pay law | WAC 284-170-431 | 5 |
| NEMT | Regional broker model | 7 |
| EVV | Provider choice model | 9 |
Washington Apple Health (Medicaid)
Washington Apple Health (Medicaid) is run by the Washington State Health Care Authority (HCA). Fee-for-service claims and provider enrollment go through ProviderOne1, at www.waproviderone.org. Integrated managed care: five Apple Health plans are offered across 10 integrated managed care regions, with four or five of them available in each region2. UnitedHealthcare Community Plan of Washington is offered in the six western regions and not in North Central, Spokane, Greater Columbia or Southwest Washington. Apple Health Foster Care is statewide and is provided through Apple Health Core Connections, run by Coordinated Care of Washington.
Fee-for-service filing limit: 365 calendar days from the date of service for the initial claim to reach HCA and be assigned a transaction control number (TCN)4. The 365 days can instead run from a final fair hearing decision, a court order, or HCA's delayed certification of the client's eligibility. When Medicare pays first, the claim is due no more than six months after Medicare processes it. A timely claim can be resubmitted, modified or adjusted for up to 24 months from the date of service, or 15 months for prescription drug claims. If a claim is denied because these limits were missed, neither the provider nor its billing agent may bill the client. Managed care plans set their own limits in their provider manuals, so the deadline on a Washington Medicaid claim depends on which plan holds the member on the date of service.
Managed care plans2
- Community Health Plan of Washington
- Coordinated Care of WashingtonAlso runs Apple Health Core Connections for foster care
- Molina Healthcare of Washington
- UnitedHealthcare Community Plan of WashingtonSix western regions
- Wellpoint WashingtonPreviously Amerigroup
Each plan is credentialed separately, has its own portal and its own appeal route. A practice that joins Washington Medicaid through one plan is not in network with the others until each contract is in place.
Commercial payers and the prompt-pay law
Commercial payers active in Washington6: Premera Blue Cross, Regence BlueShield, Kaiser Foundation Health Plan of Washington, LifeWise Health Plan of Washington, Coordinated Care Corporation, Molina Healthcare of Washington, Inc., Community Health Plan of Washington, Wellpoint Washington, Inc. A Washington practice works to a separate provider manual for each, with its own filing window, corrected-claim process and appeal levels. Verified payer deadlines, each with its source, are in the timely filing limits table.
Clean-claim payment window under WAC 284-170-431: 95 percent of each month's clean claims paid within 30 days of receipt, and 95 percent of all claims paid or denied within 60 days5. A carrier that misses the standard owes 1 percent simple interest per month on unpaid, undenied clean claims more than 61 days old, added to the payment without a new claim from the provider. Every denial has to give its specific reason, and for a medical necessity denial the carrier must disclose the supporting basis on request. The receipt date is the day the carrier or its agent receives written or electronic notice of the claim. Where the statute earns its place is A/R follow-up: a clean claim that outlasts the window is escalated with the statute cited, and interest is requested where Washington law provides it.
NEMT and home care in Washington
Non-emergency medical transportation. Regional broker model: HCA contracts with six transportation brokers, each assigned a set of counties, that schedule nonemergency rides for Apple Health clients: Northwest Regional Council, Hopelink, Paratransit Services, Community in Motion (formerly Human Services Council), People for People and Special Mobility Services7. The broker serving the client's county is the first point of contact for any transportation complaint, and HCA's NEMT program sits behind the brokers. The NEMT billing in Washington page covers trip documentation, broker claims and reconciliation.
Electronic visit verification. Provider choice model: home care agencies pick their own EVV system, individual providers employed by Consumer Direct Care Network of Washington use the CDWA system, and ProviderOne is the state's data aggregator, receiving the required EVV data elements with each claim9. EVV covers Medicaid-funded in-home personal care, respite and home health care services. Individual providers who live with their client are exempt, but every caregiving employee of a home care agency must use EVV for each shift, and home health agencies billing ProviderOne follow HCA's home health EVV requirements. See home care billing in Washington for waiver programs, EVV exceptions and authorizations.
Rules that change how Washington claims are billed
Apple Health telemedicine goes on POS 02 or 10, with modifier 95 for nonfacility sites10
HCA wants POS 02 when the client is somewhere other than home and POS 10 when the client is at home. A distant site designated as nonfacility adds modifier 95 to get the nonfacility rate, although licensed behavioral health agencies billing under the SERI, mental health or SUD guides and health home providers do not use it. HCA dropped modifier GT for professional claims, except for practitioners billing under the Critical Access Hospital optional payment method. When Medicare is primary, follow CMS modifier guidance instead.
Audio-only visits need an established relationship, documented consent and modifier 93 or FQ10
Apple Health covers audio-only telemedicine only when the practitioner already has an established relationship with the client, and consent has to be obtained and documented in the record before the service. Claims carry modifier 93, or FQ for counseling and therapy under the SERI, SUD and mental health guides. A visit that was partly video and partly phone counts as audio-only when half or more of it was delivered by audio alone.
HCA does not pay, or pay secondary, for services a plan covers1
When the eligibility response shows a managed care segment for the date of service, the claim goes to the plan, and HCA will not process it, even as secondary payer. Bill ProviderOne directly only when there is no managed care segment, or the plan's segment has ended before the dates billed. If a client is in a plan when admitted to the hospital and becomes fee-for-service during the stay, the plan stays responsible for the entire stay and the physician services until discharge.
Revalidation gives 30 days from the notice, then 90 more after deactivation notice11
HCA mails one revalidation letter to the group or facility at the ProviderOne mailing address, not to each clinician. You have 30 days from the date on the notice before HCA sends a deactivation notice, then 90 more days before billing privileges are affected. Billing providers work through Manage Provider Information in ProviderOne, including updated ownership and control disclosures; clinicians who serve Apple Health clients only through a managed care entity are nonbilling providers, have no ProviderOne access and send documents through the HCA support portal.
Services for Washington practices
Remitwright serves Washington practices remotely, inside the practice management or EHR system the practice already uses. A dedicated biller works the account; nothing is pooled. Each service below explains what that biller does.
- Medical billingClaims worked by one named biller
- CredentialingEnrollment, CAQH and PECOS kept current
- Eligibility verificationCoverage and benefits checked before visits
- Prior authorizationAuths requested, tracked, attached to claims
- Denial managementEvery denial read, worked and appealed
- A/R follow-upUnpaid claims chased before filing limits
FAQ
Questions from Washington practices
What is the Washington Apple Health timely filing limit?
Our patient left their Apple Health plan in the middle of a hospital stay. Who pays?
Which place of service and modifier do we use for an Apple Health video visit?
Can we bill Apple Health for a phone-only appointment?
We got an HCA revalidation letter. How long do we have?
Our clinicians only see Apple Health plan members. Do they deal with HCA at all?
How do our Apple Health patients get a ride to appointments?
Which managed care plans run Medicaid in Washington?
How quickly must insurers in Washington pay a clean claim?
Does Washington require EVV for home care visits?
Who runs Medicaid in Washington, and where do fee-for-service claims go?
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