Core Provider Agreement and National Provider Identifier for Medicaid Services

Please see more information and FAQs below regarding the Core Provider Agreement.

Q: What is a Core Provider Agreement (CPA)? Why is a CPA required?

A: The Code of Federal Regulations (federal law) mandates that the Washington State Health Care Authority (HCA) require a CPA so the HCA can enroll eligible providers in its Apple Health Medicaid program to pay those providers for covered services, supplies, and equipment rendered to eligible Apple Health clients. In addition, Washington Administrative Code (WAC) allows the option for providers who do not bill Medicaid but write orders and prescriptions for services Medicaid pays for to have “an approved agreement with the agency [HCA] as a nonbilling provider.” Providers and Community Health Plan of Washington (CHPW) must comply with the federal mandate.

The requirements have been in place for several years. However, validation that providers who are enrolled with managed care plans meet the requirements has not previously occurred.

The HCA requires contracted Managed Care Organizations (MCOs) such as CHPW to report encounter data for purposes of quality assurance, risk adjustment, rate development, and Service Based Enhancement (SBE) payments. Data reporting must include all medical healthcare and pharmacy services delivered to eligible Medicaid clients.

The HCA has begun enforcing the federal requirement by rejecting encounters submitted by MCOs that contain any NPI that is not “known” to the HCA.

To ensure that a provider’s NPI is “known” to the HCA, the provider must have either a valid CPA or a Nonbilling Individual Provider Agreement (“nonbilling agreement” or NBA). The HCA provided information about this in a letter it sent to providers earlier this year. A copy of the letter is available on our website at http://chpw.org/resources/Providers/CPA_Letter_HCA.pdf. A completed CPA or nonbilling agreement registers your NPI with (makes your NPI known to) the state.

The HCA recognizes these types of providers:

  • Participating enrolled providers who bill through Washington State’s Medicaid billing and payment system, ProviderOne; and
  • Nonbilling providers who may or may not have a contract with an MCO and do not bill fee-for-service (FFS) through ProviderOne.

If you wish to enroll with Medicaid as a provider, please go to https://www.hca.wa.gov/billers-providers/apple-health-medicaid-providers/enroll-provider for more information and to access the HCA Core Provider Agreement.

If you wish to be an HCA nonbilling provider (you do not bill FFS through ProviderOne), you still need to take action: Go to http://www.hca.wa.gov/billers-providers/apple-health-medicaid-providers/enroll-non-billing-individual-provider for more information and to access the Nonbilling Individual Provider Agreement.

You can find additional information that may assist you at:

                - 182-502-0005 Core provider agreement (CPA), http://app.leg.wa.gov/wac/default.aspx?cite=182-502-0005
                - 182-502-0006 Enrollment for nonbilling individual providers, http://apps.leg.wa.gov/wac/default.aspx?cite=182-502-0006
                - 182-502-0120 Payment for health care services provided outside the state of Washington,                                               http://apps.leg.wa.gov/wac/default.aspx?cite=182-502-0120

The Health Care Authority has postponed the October 1, 2016 implementation date for requiring a Core Provider Agreement and posing potential penalties. A future date for implementation has not been determined at this time.  Further information regarding this requirement will be communicated as soon as available. As a result, CHPW will be postponing any action.

Q: Do I need both a CPA and a nonbilling agreement?

A: No, you cannot have both a CPA and a nonbilling agreement. If you already have a CPA and you complete a nonbilling agreement, the existing CPA will be terminated and replaced by the nonbilling agreement. Please refer to http://www.hca.wa.gov/billers-providers/apple-health-medicaid-providers/enroll-non-billing-individual-provider for more information.

Q: Do I need a CPA or nonbilling agreement if I am not located (do not practice) in Washington State?

A: Yes. If you serve Washington Apple Health (Medicaid) clients, you need either a CPA or a nonbilling agreement.

Q: If I complete a nonbilling agreement, does that change the way I manage my practice or the patients that I see?

A: No. Having a completed HCA nonbilling agreement does not change which patients you see, how you serve your patients, or the way you manage your practice or business.

If you are an HCA nonbilling provider (you do not bill FFS through ProviderOne) and you have a nonbilling agreement:

  • You are not obligated to see Medicaid members; and
  • The HCA will not ask you to see Medicaid clients; and
  • The HCA will not give your name to Medicaid clients.

Q: Is there a penalty if I don’t complete a CPA or nonbilling agreement?

A: Possibly.

Providers who do not have a CPA or nonbilling agreement for Apple Health but who are already known to CMS or another Medicaid program or agency will not be penalized.

Providers who do not have a CPA or nonbilling agreement for Apple Health and are not already known to CMS or another Medicaid program or agency could be assessed a penalty by the HCA. Any penalties would be based on dates of service October 1, 2016 and forward.

Effective June 1, 2016, the HCA charges certain provider types an application fee for the CPA. Please refer to http://www.hca.wa.gov/billers-providers/apple-health-medicaid-providers/enroll-billing-provider and http://www.hca.wa.gov/assets/application-fee-faq.pdf for more information.

Q: If I (or my organization) already registered an NPI, does the NPI registration date need to match the CPA or nonbilling agreement effective date?

A: Your NPI registration date does not need to match your CPA or nonbilling agreement effective date. However, your NPI effective date must occur before dates of service for submitted encounters and claims.

Example

  • A provider registers an NPI June 1, 2016.
  • The provider completes a CPA that becomes effective September 1, 2016.
  • In October 2016, the provider submits claims with dates of service from December 2015.
  • The encounters would be rejected by the HCA for missing, invalid, or unrecognized NPI.
  • Please note that, as stated in the ProviderOne Billing and Resource Guide (http://www.hca.wa.gov/assets/billers-and-providers/providerone_billing_and_resource_guide.pdf, page 16), HCA does not pay for services during the CPA application process.

Example

  •  A provider submits a CPA application to the HCA electronically on September 1, 2016. This can take up to 30 days to process (see question & answer 8 below).
  • The provider bills for services provided to a Medicaid client on September 23, 2016.
  • The provider’s CPA application is approved on September 29, 2016.
  • The HCA (and therefore CHPW) would not pay for any services provided prior to September 29.
  • The provider bills for services provided to a Medicaid client on October 10, 2016.
  • The HCA (and therefore CHPW) would pay for covered services provided after the provider’s CPA effective date of September 29.

Q: Why isn’t being registered with NPPES (the National Plan and Provider Enumeration System) good enough? Why do I need to register through HCA of Washington in addition?

A: NPPES is a national system created by the Centers for Medicare & Medicaid Service (CMS) in response to the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). NPPES is not specific to Washington State. As noted in question & answer 1, a completed CPA or nonbilling agreement registers your NPI with the state, which is the requirement CMS expects the HCA to achieve.

Q: How can I find out my CPA or Nonbilling Individual Provider Agreement status with HCA?

A: You can check your CPA enrollment status with the HCA online through ProviderOne, https://www.waproviderone.org/ecams/PortalServlet. CPA applications submitted online take up to 30 days to process. CPA applications submitted by hard copy take up to 90 days to process.

Nonbilling agreements must be submitted by hard copy and take to up to 90 days to process. (An electronic option for nonbilling agreements does not currently exist. You will need to call or email the HCA. See below for contact information.)

If you have questions about your CPA or nonbilling provider enrollment application, you can call the HCA at 1-800-562-3022, ext. 16137 or email ProviderEnrollment@hca.wa.gov.

Q: I haven’t heard about this from other health plans that have Medicaid enrollees. Is CHPW the only plan that requires a CPA?

A: This is not a requirement of CHPW or any health plan or MCO. Federal law and CMS require that HCA know the NPIs of all providers who provide services to all Medicaid clients. Please see question & answer 1 for more information.

Q: My credentialing office is in the process of completing an HCA revalidation checklist. Is the revalidation somehow connected with registering an NPI and beginning the CPA process?

A: No, this is not related to your revalidation. HCA’s Core Provider Agreement specifically states: “The Provider must provide its NPI to HCA (if eligible for an NPI) and include its NPI on all claims submitted.” Please refer to http://www.hca.wa.gov/assets/billers-and-providers/core-provider-agreement-pdf.pdf, item 6.

If you are contracted with CHPW, we will now ask for proof of your CPA or nonbilling status as part of our re-credentialing process.

Q: How will my encounters and claims be impacted if I have an NPI and a CPA but I’m not contracted with CHPW (non-participating/non-par)?

A: If you already have a valid NPI and a CPA (or a nonbilling agreement), you should not need to take any action regardless of your contract status with CHPW. Your encounters will be accepted by HCA and CHPW will pay your claims according to our normal process.

Q: I work for a large organization with several locations and multiple NPIs. How do I find out if any of our NPIs are registered with the HCA or tied to a CPA or nonbilling agreement?

A: You can check your CPA enrollment status with the HCA online through ProviderOne, https://www.waproviderone.org/ecams/PortalServlet. CPA applications submitted online take up to 30 days to process. CPA applications submitted by hard copy take up to 90 days to process.

Nonbilling agreements must be submitted by hard copy and take to up to 90 days to process. (An electronic option for nonbilling agreements does not currently exist. You will need to call the number below or email the HCA.)

If you have questions about your CPA or nonbilling provider enrollment application, you can call the HCA at 1-800-562-3022, ext. 16137 or email ProviderEnrollment@hca.wa.gov.

Q: If my organization has multiple NPIs, do we need to register all of our NPIs and have a CPA for each one?

A: Yes, you need to register each of your NPIs and complete a CPA or nonbilling agreement for each NPI. You also need to use your registered NPIs for billing purposes (submitting claims).

Q: If only one NPI is registered, how are claims (billing) impacted when the NPI used on the claim is not associated with the location billing?

A: Encounters will reject when submitted to HCA and will not be included in premium rate setting and enhancement payments. In addition, CHPW will deny claims for rejected encounters and, when necessary, recoup paid claims.

Q: When a facility has a CPA or nonbilling agreement, how are the individual providers impacted?

A: Both the billing provider and the rendering (professional) or attending (institutional) provider NPIs must have a CPA or nonbilling agreement.

Q: What if I have questions that aren’t addressed in this FAQ?

A: Please contact HCA at 1-800-562-3022, ext. 16137 with questions about a CPA or nonbilling agreement.

Please contact Provider.Changes@chpw.org if you have questions for Community Health Plan of Washington.