Washington State Health Care Authority EDI And Enrollment Requirements
Washington State Health Care Authority EDI program works under general HIPAA standard requirements. Health Insurance Portability and Accountability Act (HIPAA) Electronic Data Interchange (EDI) is an electronic method of communicating standard transactions between covered entities (providers, clearinghouses and health plans). HIPAA EDI allows covered entities to submit and retrieve the HIPAA mandated transactions from Washington State Medicaid. Covered entities (clearinghouses, providers, health plans) are required to successfully complete EDI testing for each HIPAA transaction they plan to use in Washington State Health Care Authority EDI operation.
Implementation guide and codes
The following materials are available from Washington Publishing Company to assist you in your submissions:
- Implementation guides (TR3)
- Provider taxonomy codes
- Claim adjustment reason codes (CARC)
- Remittance advice remark codes (RARC)
- Claim status codes
Guidelines to prepare for the enrollment process
- Verify you are an eligible provider.
- Determine your provider type for enrollment.
- Complete the supplemental paperwork for your provider type.
- Use Washington State Health Care Authority enrollment manuals to complete your enrollment in the ProviderOne application.
- Review new provider next steps.
- Before you begin your application, select the provider type that matches your situation (see below).
This application process is for licensed health care professionals enrolling with the Health Care Authority (HCA) as:
- A solo practice, or
- Licensed health care groups and facilities (including suppliers and contractors of service)
All billing providers must complete and sign a Core Provider Agreement and other required documents with the agency.
Health care professional practicing under a group or facility
This application process is for licensed health care professionals who wish to enroll with the Health Care Authority (HCA) as a performing provider practicing under a group or facility. The group or facility must be enrolled with HCA, and have a Core Provider Agreement with the agency.
Non-billing individual provider
The non-billing individual provider application process is for individual health care professionals who wish to enroll for the sole purpose of ordering, referring and prescribing services.
The billing agent/clearinghouse application process is for a billing agent/clearinghouse (BA/CH) to be enrolled with Washington Apple Health (Medicaid) to ensure the flow of electronic data resulting from the submission and retrieval of HIPAA transactions can be tracked.