Overview of prior authorizations (PAs), claims and billing

Step one: Before you begin

Understand the provider process

As an Apple Health provider, your process looks like this:

1. Determine if your client is eligible for services or has a primary payer.
2. Meet with your patient or client to determine what services are needed.
3. Request prior authorization (PA) for those services—if required—from HCA.
4. Perform the service for your patient or client.
5. Submit a claim to HCA for payment for those services.

Make sure you have a ProviderOne profile

ProviderOne is the online billing and claims system you use for submitting your claims.

A ProviderOne profile (user account) is setup for you by either your organization's system administrator or ProviderOne Security (if you are the system administrator) when you complete your Apple Health enrollment.

I do not have a profile

• If your organization is new to ProviderOne, you must establish a system administrator. The system administrator will create all profiles for your organization. To create a system administrator profile, contact ProviderOne Security for assistance.
• If you are a user who will be submitting claims for your organization and do not have a ProviderOne profile, contact your organization's system administrator.

Access the ProviderOne Billing and Resource Guide

The ProviderOne Billing and Resource Guide gets you started using ProviderOne. This is a general guide that:

• Helps you determine the eligibility of a client.
• Explains the prior authorization (PA) process.
• Walks you through the process of submitting claims through direct data entry (DDE) using the provider portal.

Step two: Determine if you need a (PA) for services

Some services require prior authorization (PA) before you can provide the service. To determine if a PA is required and learn how to submit a PA to the Health Care Authority (HCA), visit our Prior authorization (PA) page for step-by-step instructions.

Step three: Complete your claim

Once you've provided services to your client, log into ProviderOne and complete your claim.

Tools to help you file a claim

Review the ProviderOne Billing and Resource Guide

Our ProviderOne Billing and Resource Guide walks you through the process of submitting claims. For additional training materials, visit the Learn ProviderOne page.

Access specific fee schedules and billing guides

Utilize the rate information and billing guides available for specific programs:

• Professional rates and billing guides
• Hospital rates and billing guides

Submit backup documentation

Use the document submission cover sheets to submit your backup, if necessary.