ProviderOne
DSHS Home Page
 
Search     for:


DSHS Home    Acronyms    Alerts    Screens    WAC Number Index    WCCC

ProviderOne


Revised July 5, 2012



What is the ProviderOne interface?

 

How often does the ProviderOne interface take place?

 

What information is sent from ACES to ProviderOne?

 

What information is received from ProviderOne to ACES?

 

How do I access Third Party Liability Organization information?

 

How do I access Provider and Rate information?

 



What is the ProviderOne interface?

 

·         The ProviderOne interface is an exchange of information between ACES and the Health and Recovery Services Administration’s (HRSA) ProviderOne system.

 

·         ProviderOne uses this information to authorize payment for medical bills from medical providers, generate reports, and obtain federal funding.

 

·         ACES uses the data received from ProviderOne to automatically update the appropriate screens with the new or updated medical information data, Third Party Liability (TPL) data, provider data, and rate information.

 

How often does the ProviderOne interface take place?

 

·         The ProviderOne interface takes place on a daily, weekly, and monthly basis depending on what client or provider information is being exchanged.

 

What information is sent from ACES to ProviderOne?

 

·         The Eligibility Interface file contains client demographic, medical eligibility, spenddown, and TPL information.

 

o    ACES sends this file to ProviderOne in the overnight batch process.

 

o    The real-time version of this interface is sent throughout the day at approximately 15 minute intervals for clients who need medical services the same day their medical application is approved. See Initial Issuance and Finalize Application chapters.

 

What information is received from ProviderOne to ACES?

 

·         The Daily Facility Updates file provides demographic and rate information for the various Long Term Care, Managed Care, and Take Charge medical providers.

 

o    When new providers are added or changes are made to the information of existing providers, ACES updates the PROV screen with the new information.

 

o    This file is received daily.

 

·         The Client TPL Insurance file indentifies clients who have medical coverage through a third party, provides information about the insurance organization and other pertinent information related to the client’s coverage.

 

o     ACES updates the client’s TPL1 screen with the current TPL information that is sent.

 

o    Included in this TPL file is Medicare data (MEDA and MEDB) which is used to ensure clients are added or deleted from the State’s Medicare Buy-In program.

 

    The Medicare Buy-in data received from ProviderOne automatically updates changes of Medicare Part A and Part B premium payment data on the TPL1 screen in the Paid By field.

 

    ACES also uses the transaction data to update clients’ Medicare (Title XVIII) data.

 

o    This interface file is received weekly.

 

·        The Managed Care Updates file identifies recipients enrolling and dis-enrolling on the following Managed care programs: Program of All-inclusive Care for the Elderly (PACE), Washington Medicaid Integration Project (WMIP), or Basic Health Plan Plus (BHPP) service providers.

 

o     Information sent includes the client’s enrollment date, provider name and phone number, disenrollment date and reason. If the client has and Managed Care information, the information will auto-populate on the client’s MANC screen.

 

o    This file is received monthly.

 

·         The Insurance Organization file identifies all the Insurance Organizations and all their pertinent information.

 

o    ACES updates the TPLC screen with the names, addresses, and carrier codes of all TPL carriers known to the state.

 

o    This file is received monthly.

      

·         The ProviderOne Web Service provides real-time information.

 

o    This file populates the Client >>Medical Information page in aces.online. For more information see the Medical Information chapter.  

 

o    Data elements displayed are:

¨        ProviderOne ID number

¨        Medicare

¨        TPL Insurance

¨        Relative Care Placement Indicator

¨        Hospice Indicator

¨        Restriction Indicator

¨        DDD Client Indicator

 

o    Managed Care Information:

¨        Health Plan

¨        Program

¨        Start Date

¨        End Date

 

How do I access Third Party Liability Organization information?

 

·        TPL Organization information can be accessed using the Health Organization name or Health Organization code.

 

1.    If you know the Organization name, from the LMEN screen:

 

o    Enter [F – Health Insurance Orgs – By Name]  in the Selection field.

 

o    Enter the [Organization Name] in the Organization Name field.

 

2.    Press <Enter> and the TPLL screen displays.

 

3.    On the TPLL screen, enter a [Y] in the Sel field that corresponds to the Organization name, press <F3> and the TPLC screen displays.

 

OR

 

1.    If you know the Organization code, from the LMEN screen:

 

o    Enter [G - Health Insurance Orgs – By Code] in the Selection field.

 

o    Enter the [Organization Code] in the Organization  field.

 

2.    Press <Enter> and the TPLC screen displays.

 

How do I access Provider and Rate information?

 

1.    On the MMEN, enter [D] in the Selection field to display a list of medical providers.

 

o    Entry in one of the following fields is required:

 

    Name  – Use this field to enter a full or partial name to find a provider/vendor. 

 

    EIN/SSN/TIN  – Use this field to locate or inquire on a provider/vendor using a Tax ID or Social Security number. 

     

    City  – Use this field to locate or inquire on a provider/vendor located in a specific city.   

   

2.    On the PRLS screen, enter [Y] in the Sel field to view the PROV screen for a specific provider.

Modification Date: July 5, 2012