Usual & customary fee

The rate that may be billed to the agency for a certain service or equipment. This rate may not exceed either of the following:

1) The usual and customary charge that you bill the general public for the same services 

2) If the general public is not served, the rate normally offered to other contractors for the same services

Client Eligibility

How can I verify a patient’s eligibility?

Providers must verify that a patient has Washington Apple Health coverage for the date of service, and that the client’s benefit package covers the applicable service. This helps prevent delivering a service the agency will not pay for.

 Verifying eligibility is a two-step process:

Step 1. Verify the patient’s eligibility for Washington Apple Health. For detailed instructions on verifying a patient’s eligibility for Washington Apple Health, see the Client Eligibility, Benefit Packages, and Coverage Limits section in the agency’s current ProviderOne Billing and Resource Guide. If the patient is eligible for Washington Apple Health, proceed to Step 2. If the patient is not eligible, see the note box below. 

Step 2. Verify service coverage under the Washington Apple Health client’s benefit package. To determine if the requested service is a covered benefit under the Washington Apple Health client’s benefit package, see the agency’s Program Benefit Packages and Scope of Services web page. 

Note: Patients who are not Washington Apple Health clients may submit an application for health care coverage in one of the following ways: 

1. By visiting the Washington Healthplanfinder’s website at: www.wahealthplanfinder.org 

2. By calling the Customer Support Center toll-free at: 855-WAFINDER (855-923-4633) or 855-627-9604 (TTY) 

3. By mailing the application to: Washington Healthplanfinder PO Box 946 Olympia, WA 98507 In-person application assistance is also available. 

To get information about inperson application assistance available in their area, people may visit www.wahealthplanfinder.org or call the Customer Support Center. 

Clients age 20 and younger who are receiving services under a Benefit Package:

Are eligible for the covered hearing aids and services listed in this billing guide and for the audiology services listed in the agency’s Physician-Related Services/Health Care Professional Services Billing Guide. 

 Must have a complete hearing evaluation, including an audiogram and/or developmentally appropriate diagnostic physiologic test results performed by a hearing healthcare professional. 

Must be referred by a licensed audiologist, otorhinolaryngologist, or otologist for a hearing aid.

Hearing aids are covered under agency-contracted managed care organizations (MCO). Clients who are enrolled in an agency-contracted MCO are eligible for covered hearing aids. Bill the MCO directly for these services. Additionally, clients enrolled in an agency-contracted MCO must obtain replacement parts for cochlear implants and bone anchored hearing aids (Baha®), including batteries, through their MCO.