Manuals, Forms and Resources

• Provider Manual for Medicaid & Foster Care (PDF)
• Benefits Grid - Washington Apple Health (PDF)
• Claims Billing Cheat Sheet (PDF)
• HEDIS Guides
• Sport Physical to EPSDT Visit Tool (PDF)
• Prior Authorization Guide for Integrated Managed Care (IMC) and Behavioral Health Services Only (BHSO) (PDF)
• Provider Prior Authorization Reference Guide (PDF)
• Provider Quick Reference Guide (PDF) 
• Apple Health Applied Behavioral Analysis Program Billing Guide (PDF) - behavioral 

• Appeal Form for Member Authorized Representative (PDF)  
• Applied Behavioral Analysis Prior Authorization form (PDF) - behavioral
• BioPharmacy/Buy-Bill Prior Authorization Form (PDF)
• Coordinated Care's External Critical Incidents Notification Form (PDF)
• Hysterectomy Consent Form (PDF)
• Notification of Pregnancy (NOP) - Provider form (PDF)
• Ophthalmology Pre-Authorization Request Form (PDF) 
• Outpatient/Inpatient Behavioral Health Service Authorization Request Form (PDF) - behavioral
• Outpatient Physchological Testing Prior Authorization form (PDF) - behavioral
• Ownership and Controls Disclosure Form (PDF)
• PACT Notification and Continuation of Service Request (PDF)
• Prior Authorization: Electroconvulsive Therapy (ECT) (PDF) - behavioral
• Prior Authorization/Referral Form – Inpatient (PDF) - medical and behavioral
• Prior Authorization Form – Outpatient (PDF) - medical and behavioral
• Prior Authorization Form - Transcranial Magnetic Stimulation Initial Request form (PDF) - behavioral
• Provider Demographic Change Form (PDF)
• Provider Request for Breast Pump Form for Nursing Mother
• Stage 2 Bariatric Surgery Request (PDF)
• Sterilization Consent Form (PDF)
• WISe Services Notification Form (PDF)
• W-9 Form (PDF)

BH Levels of Care Sheet

• AHCC BH Levels of Care One Pager (Foster Care) (PDF) - Spanish
• AHCC BH Levels of Care One Pager (Foster Care) (PDF) - English
   

Fact Sheets

ADHD

• ADHD Fact Sheet (PDF)
• ADHD Toolkit (PDF)

Anxiety

• Anxiety Fact Sheet (PDF)
• Anxiety Toolkit (PDF)

Depression

• Depression Fact Sheet (PDF)
• Depression Toolkit (PDF)

Substance Use

• Substance Use Fact Sheet (PDF)
• Substance Use Toolkit (PDF)

Collaborative Care is a specific type of integrated care where medical providers and behavioral health providers work together to address behavioral health conditions, including mental health and substance use disorders.

1. Collaborative Care is intended to enhance usual primary care by adding two key services:
   Care management support for patients receiving behavioral health treatment; and 
2. Regular psychiatric consultation with the primary care team, particularly clients whose conditions are not improving. (WAC 182-531-0425)

Completing the Washington Health Care Authority's (HCA) Attestation form is required for providers to indicate they meet the standards. The form is found on HCA's Forms and Publications page on their web site, or by searching for 13-0017. 

The completed attestation form needs to be sent to the HCA at providerenrollment@hca.wa.gov before billing for these codes.

• MemberConnections Referral Instructions (PDF)
• MemberConnections Referral Form (PDF)
• Member Connections Referral Follow Up (PDF)

• Advance Directives and POLST 
• Contraception Coverage Fact Sheet (PDF)
• Discharge Planning and Inpatient Utilization Management: 1-844-208-8885
• Down Syndrome Support Networks and Programs for Families (PDF)
• HPV Cancer Prevention: The Importance of the HPV Vaccine 
• Immunization Coverage Rate Report (PDF)
• Lead Poisoning Prevention
• Medically Intensive Children's Program (MICP) flyer - English (PDF)
• Medically Intensive Children's Program (MICP) flyer - Spanish (PDF)
• Member Rights and Responsibilities
• Partnership Access Line (PDF)
• Smoking Cessation Program Description
• Transplant Check List (PDF)

• Please contact NIA for authorization

• Reconsideration Grid (Medicaid) (PDF)
  

• Adminstrative Day Request form (PDF)
• Claim Reconsideration and Dispute form (PDF) - Do not use for 14 Day Readmission Appeals
• Certified Public Expenditure facility-SSI Reconsideration Form (PDF)
• Re-Review Request form (PDF)

• Contact Envolve Vision for Authorization
• Envolve Vision Provider Manual (PDF)
  • Appendix: Coordinated Care Apple Health Plan Specifics (PDF)
  • Appendix: Apple Health Core Connections (PDF) (foster care)

• National Laboratory Vendors (PDF)
• CMS required 2013 Jimmo v. Sebelius class action lawsuit
  • Medicare Learning Network: Jimmo v.  Sebelius Settlement Agreement slides (PDF)
  • Summary of questions and responses during the Dec. 16 2013 Jimmo vs. Sebelius National Call for contrators and adjudicators (PDF)

Providers can request Provider Policies and Procedures by contacting our Provider Services Department at 1-877-644-4613 (TDD/TTY 1-866-862-9380) and a representative will assist you.