Washington - Occupational Therapy Service — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The Washington State Department of Health (DOH) licenses Occupational Therapists under Chapter 18.59 RCW, and the Health Care Authority (HCA) enrolls them to provide waiver-funded services through the ProviderOne system.

Approval to bill Apple Health for HCBS waiver participants requires an active DOH license and a Core Provider Agreement with HCA, alongside specific contracting with the Developmental Disabilities Administration (DDA) for waivers such as Basic Plus and Core.

1. Service Definition and Scope

In Washington, Occupational Therapy under HCBS waivers provides evaluation and treatment to restore or maintain a participant's function in daily occupations. These services are authorized when they exceed the limits of the Medicaid State Plan.

The service includes therapeutic interventions, adaptive equipment recommendations, and caregiver training to support the waiver participant's independence in their home and community.

• Service Scope: Evaluation and treatment to restore or maintain function in daily occupations.
• Waiver Coverage: Available under DDA waivers including Basic Plus, Core, and Community Protection.
• State Plan Exhaustion: Waiver OT is only authorized after State Plan OT benefits are exhausted or not applicable.
• Caregiver Training: Includes instructing family members or direct support professionals on therapeutic exercises.
• Adaptive Equipment: Encompasses assessing the need for and training on the use of specialized equipment.
• Settings: Delivered in the participant's home or community settings rather than clinical facilities.

2. Regulatory and Oversight Agencies

Multiple state agencies oversee the licensure, enrollment, and authorization of Occupational Therapy services in Washington. Providers must interact with health licensing, Medicaid finance, and disability services divisions.

The Department of Health handles professional licensure, while the Health Care Authority manages the ProviderOne MMIS for Medicaid enrollment and claims.

• Washington State Department of Health (DOH): Licenses Occupational Therapists and Assistants (https://doh.wa.gov).
• Washington State Health Care Authority (HCA): Administers Apple Health and the ProviderOne enrollment portal (https://www.hca.wa.gov).
• Developmental Disabilities Administration (DDA): Authorizes waiver services and manages participant care plans (https://www.dshs.wa.gov/dda).
• Aging and Long-Term Support Administration (ALTSA): Oversees waivers for older adults and individuals with physical disabilities (https://www.dshs.wa.gov/altsa).
• ProviderOne: The official Washington MMIS and provider enrollment portal (https://www.waproviderone.org).

3. Gatekeeping Prerequisites: Who Can Even Apply

Washington requires an active professional license before any Medicaid enrollment application is accepted. There is no separate HCBS agency license for independent OT providers; the professional license acts as the primary gate.

Providers must also secure a National Provider Identifier (NPI) and maintain active malpractice insurance before initiating the ProviderOne application.

• Professional Licensure: Must hold an active Occupational Therapist license issued by the Washington State DOH.
• NPI Requirement: Must possess a Type 1 NPI for individuals or Type 2 NPI for group practices.
• Business Registration: Entities must have a valid Employer Identification Number (EIN) and Washington State business license.
• Malpractice Insurance: Must maintain current professional liability insurance.
• State Plan Enrollment: Must enroll as a standard Apple Health provider before receiving waiver-specific authorizations.

4. Licensure and Certification Requirements

The Washington State Department of Health (DOH) governs the practice of Occupational Therapy under Chapter 18.59 RCW. Applicants must submit proof of education, examination, and background checks.

Out-of-state applicants must provide credential verification from all states where they have held a license. DOH processes applications online or via paper packets.

• Statutory Authority: Governed by Chapter 18.59 RCW and WAC 246-847.
• Education: Must graduate from an ACOTE-accredited occupational therapy program.
• Examination: Must pass the NBCOT certification examination.
• Jurisprudence: Must complete the Washington State jurisprudence examination.
• Continuing Education: Requires 30 hours of continuing education every two years for license renewal.
• Out-of-State Verification: Requires the Out-of-State Credential Verification form for any prior licenses held.

5. Medicaid Provider Enrollment

Medicaid enrollment is processed through the HCA's ProviderOne system. Providers must select the correct enrollment type and submit a Core Provider Agreement.

Institutional or group providers may be subject to an application fee, which is set annually by CMS. Individual practitioners enrolling solely to provide services typically bypass this fee.

• Enrollment Portal: Applications must be submitted via the ProviderOne system.
• Application Fee: The institutional application fee is $730 for 2025 and $750 for 2026.
• Core Provider Agreement: Must sign and submit the HCA Core Provider Agreement.
• Debarment Statement: Requires a signed statement certifying the provider is not excluded from federal programs.
• W-9 Form: Must submit a completed W-9 for tax identification purposes.
• CAQH ProView: HCA utilizes CAQH ProView for credentialing data, requiring re-attestation every 120 days.

6. Staffing, Training and Background Checks

All occupational therapy providers must pass comprehensive background checks before licensure and Medicaid enrollment. DOH and HCA coordinate to ensure providers have no disqualifying criminal history.

Waiver-specific training may be required by DDA for providers interacting with vulnerable adults or children in home settings.

• Background Check: Requires a fingerprint-based background check through the Washington State Patrol and FBI.
• Mandatory Reporting: Must complete training on mandatory reporting of abuse, neglect, and exploitation.
• CPR/First Aid: Must maintain current CPR and First Aid certification.
• HCBS Settings Rule: Must comply with federal HCBS Settings Rule requirements regarding participant privacy and autonomy.
• Cultural Competency: HCA requires providers to complete approved health equity and cultural competency training.

7. Documentation, Policies and Records

Providers must maintain clinical and financial records in accordance with HCA and DDA standards. Documentation must justify the medical necessity and functional goals of the therapy.

Records must be retained for a minimum of six years and be available for audit by HCA, DDA, or federal reviewers.

• Evaluation Reports: Must document baseline functional status and specific, measurable treatment goals.
• Session Notes: Requires daily treatment notes detailing interventions provided and participant response.
• Care Plan Alignment: Therapy goals must align with the participant's DDA Person-Centered Service Plan.
• Record Retention: All clinical and billing records must be kept for at least six years.
• Discharge Summaries: Must provide a summary of progress and recommendations upon discharge from the service.

8. Billing, Rates and Claims

Billing for HCBS waiver OT services is conducted through ProviderOne using standard CPT codes. Rates are established by the HCA and published in the Apple Health fee schedules.

Providers must ensure services are prior-authorized by the participant's DDA case manager before rendering treatment.

• Billing System: All claims must be submitted electronically through ProviderOne.
• Procedure Codes: Billed using standard physical medicine CPT codes (e.g., 97165 for evaluation, 97530 for therapeutic activities).
• Prior Authorization: Services must be authorized in the DDA CARE system, which transmits authorizations to ProviderOne.
• Rate Schedule: Reimbursed according to the HCA Professional Fee Schedule.
• Timely Filing: Claims must be submitted within 365 days of the date of service.

9. Approval Sequence and Timeline

The approval process follows a strict sequence: professional licensure, followed by Medicaid enrollment, and finally waiver contracting. Attempting to enroll in ProviderOne without an active DOH license results in immediate denial.

The entire process typically takes 2 to 4 months, depending on background check processing times and HCA application volumes.

• Step 1: Obtain NBCOT certification and complete DOH license application.
• Step 2: Complete fingerprint-based background checks for DOH.
• Step 3: Receive active Occupational Therapist license from DOH (typically 4-6 weeks).
• Step 4: Submit Apple Health enrollment application via ProviderOne.
• Step 5: HCA processes the ProviderOne application (strives for 30 days).
• Step 6: Coordinate with DDA for waiver service authorization and contracting.

10. Common Denials and Survey Findings

Applications are frequently delayed or denied due to administrative errors, such as selecting the wrong provider type in ProviderOne or failing to submit required supplemental documents.

During audits, the most common findings relate to insufficient documentation of medical necessity or billing for services not explicitly authorized in the care plan.

• Enrollment Denial: Selecting the incorrect enrollment type or specialty in ProviderOne.
• Missing Signatures: Failure to electronically sign the Core Provider Agreement or Debarment Statement.
• CAQH Expiration: Pending applications rejected due to an expired CAQH ProView attestation.
• Audit Finding: Session notes lacking specific details on the interventions performed and time spent.
• Audit Finding: Billing for dates of service prior to the official DDA authorization start date.

11. Key Contacts and Resources

Providers should utilize the official state portals for the most current fee schedules, billing guides, and application forms. The HCA Support Portal is the primary mechanism for resolving ProviderOne enrollment issues.

DOH provides an online credential search to verify license status, which is required before initiating Medicaid enrollment.

• HCA Support Portal: Submit enrollment questions and track application status (https://support.hca.wa.gov/hcasupport).
• DOH Licensing: Information on OT license applications and renewals (https://doh.wa.gov/licenses-permits-and-certificates/professions-new-renew-or-update/occupational-therapist-and-occupational-therapy-assistant).
• ProviderOne Portal: The login page for Medicaid enrollment and billing (https://www.waproviderone.org).
• DDA Provider Resources: Information on waiver contracting and policies (https://www.dshs.wa.gov/dda/providers-and-advocates).
• Washington State Legislature: Access to Chapter 18.59 RCW governing OT practice (https://app.leg.wa.gov/rcw/default.aspx?cite=18.59).

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