ContractInteragency Agreement Medicaid Administrative Claiming • June 21st, 2022 • Washington
INTERAGENCY AGREEMENTMedicaid Administrative Claiming (MAC) Public School Districts HCA AGREEMENT NUMBER SOLICITATION NUMBER (If Applicable)RFP #: This Agreement is made between Washington State Health Care Authority, hereinafter referred to as “HCA”, and the party whose name appears below, hereinafter referred to as the “Contractor”. CONTRACTOR AGREEMENT NUMBER CONTRACTOR NAME CONTRACTOR doing business as (DBA) CONTRACTOR ADDRESS WASHINGTON UNIFORM BUSINESS IDENTIFIER (UBI) CONTRACTOR CONTACT CONTRACTOR TELEPHONE NUMBER CONTRACTOR EMAIL ADDRESS HCA PROGRAM TITLEMedicaid Administrative Claiming (MAC) HCA DIVISION/SECTIONHealth Care Services / Medicaid Outreach HCA CONTACT NAME AND TITLE Wendy Nelson Program Manager HCA CONTACT OFFICE ADDRESS626 8th Ave SE PO Box 45530Olympia WA 98504-5530 HCA CONTACTS OFFICE TELEPHONE(360) 725-1842 HCA CONTACT EMAIL ADDRESSWendy.Nelson@hca.wa.gov IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS AGREEMENT? YES NO CFDA NUMBER(S) FFATA FORM REQUIRE
