Medicaid Enrollment Application and Agreement for Nonbilling IndividualMedicaid Enrollment Application and Agreement for Nonbilling Individual Providers • May 28th, 2021 • Washington
This form is used to enroll individuals who wish to become ordering, referring, prescribing providers, as well as individuals who wish for their nonbilling providers identifier to be identified on hospital services claims submitted to the Health Care Authority (HCA).
Medicaid Enrollment Application and Agreement for Nonbilling Individual ProvidersMedicaid Enrollment Application and Agreement for Nonbilling Individual Providers • January 4th, 2017
This form is used to enroll individuals who wish to become ordering, referring, prescribing providers, as well as individuals who wish for their nonbilling providers identifier to be identified on hospital services claims submitted to the Health Care Authority (HCA). This form should not be used to enroll with HCA as a billing individual, group, or performing provider (under a group or facility) with the intent to submit claims for reimbursement. Note: A provider cannot have both a core provider agreement (CPA) and this nonbilling individual provider agreement. For individuals submitting this form: Any existing CPA with HCA will be terminated and replaced by this agreement, and/or If your services are currently being billed to Medicaid through a group or facility, that billing process for your services will be deactivated and that group or facility will no longer be able to use your NPI as a performing provider for professional services. Any failure to submit the requested informatio
Medicaid Enrollment Application and Agreement for Nonbilling Individual ProvidersMedicaid Enrollment Application and Agreement for Nonbilling Individual Providers • January 4th, 2017 • Washington
This form is used to enroll individuals who wish to become ordering, referring, prescribing providers, as well as individuals who wish for their nonbilling providers identifier to be identified on hospital services claims submitted to the Health Care Authority (HCA).
