PDFWAC 182-502-0005
Provider enrollment—Core provider agreement (CPA) or nonbilling provider agreement.
(1) The agency only enrolls a health care professional, health care entity, supplier, or contractor of service through approval of an application for:
(a) A core provider agreement (CPA);
(b) A nonbilling provider agreement; or
(c) Adding a servicing provider under either a CPA or a nonbilling provider agreement.
(2) The agency may enter into a single case agreement or other forms of written agreements with a health care professional, health care entity, supplier, or contractor of service.
(3) Servicing providers must comply with the requirements for providers in the agreement under which they are enrolled and agency rules.
(4) Only a licensed health care professional whose scope of practice includes ordering, prescribing, or referring under their licensure may enroll as a nonbilling provider.
(5) An individual who is enrolled through a nonbilling provider agreement is exempt from the rules in WAC 182-502-0160 and may bill a client for health care services when:
(a) The provider is not enrolled with a managed care organization (MCO) that has a contract with the agency under WAC 182-538-067;
(b) The provider is not acting in their capacity as an ordering, prescribing, or referring provider of health care services for clients; and
(c) The provider documents that the client was informed prior to the delivery of services that:
(i) The provider is enrolled only for purposes of ordering, prescribing, or referring health care services for clients; and
(ii) The client may be billed for the health care services being provided.
(6) For services provided out-of-state, refer to WAC 182-501-0180, 182-501-0182, 182-501-0184, and 182-502-0120.
(7) Effective date of enrollment of a provider.
(a) Enrollment of a provider applicant is effective on the date the agency approves the provider application for enrollment or a date designated by the agency.
(b) A provider applicant may request an exception allowing an effective date earlier than the agency's approval of the provider application by submitting a written request to the agency.
(c) The request for an exception must specify the requested effective date and include an explanation justifying the earlier effective date.
(d) The agency will not authorize an effective date requested by the provider that is earlier than the effective date of any required license or certification.
(e) The agency may approve an exception as requested by the provider as follows for:
(i) Emergency services;
(ii) Agency-approved out-of-state services;
(iii) Medicaid provider entities that are subject to survey and certification by CMS or the state survey agency;
(iv) Retroactive client eligibility; or
(v) Other critical agency need.
(f) For federally qualified health centers (FQHCs), see WAC 182-548-1200. For rural health clinics (RHCs), see WAC 182-549-1200.
(g) Exceptions granted under this subsection do not supersede or otherwise change the agency's timely billing requirements under WAC 182-502-0150.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 24-23-009, s 182-502-0005, filed 11/8/24, effective 12/9/24; WSR 23-21-061, § 182-502-0005, filed 10/12/23, effective 11/12/23. Statutory Authority: 42 C.F.R. 455.410, RCW 41.05.021. WSR 13-19-037, § 182-502-0005, filed 9/11/13, effective 10/12/13. Statutory Authority: RCW 41.05.021 and 42 C.F.R. 455 subpart E Provider Screening and Enrollment requirements. WSR 12-12-032, § 182-502-0005, filed 5/29/12, effective 7/1/12. WSR 11-14-075, recodified as § 182-502-0005, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090, 74.09.080, and 74.09.290. WSR 11-11-017, § 388-502-0005, filed 5/9/11, effective 6/9/11.]