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Add Provider to Group

If adding a large number of providers, you can instead utilize one of the Roster Templates below. Select the roster based on your Provider Type. Please email the filled out roster to

This should be the name registered/affiliated with the Group NPI as reflected on the facility application or other contracts/licensure documents
Example: ‘Allergy & Immunology.’ Please do not enter any numbers or dates.
Is this a new location? *

If 'Yes' to New Location option above: Proceed in enrolling practitioners here and then navigate back to go through the Add an Additional Location form.

This is the location name that will display in the provider directory. We recommend using the name that patients are familiar with and will likely search for on the provider directory for this address.
Appears on the provider directory. This is the main, general office phone number for the location that members and other practitioners will call. Please provide only one phone number for each location. Including multiple phone numbers in the directory will make it unclear to members and other practitioners which phone number they should call.
Primary Location: Publish in Directory (Y/N) Default is Y unless contractual or extenuating circumstances apply
Primary Location: Do you carry a panel at this location (Y/N) * Any Per Diem, Float, Hospitalist or Inpatient only provider would NOT carry a panel (be available for ongoing outpatient vs episodic or inpatient only) care.

Secondary Location

Do you have a Secondary Location? *
(Specialist (SP), Primary Care Provider (PCP), Behavioral Health (BH), or Both (PCP/SP))
Secondary Address/Service Location: Wheelchair/Handicap Accessible?
Secondary Location: Publish in Directory?
Secondary Location: Do you carry a panel at this location?

Tertiary Location

Do you have a Tertiary location?
Specialist (SP), Primary Care Provider (PCP), Behavioral Health (BH), or Both (PCP/SP)
Tertiary Address/Service Location Wheelchair/Handicap Accessible?
Tertiary Location: Publish in Directory?
Tertiary Location: Do you carry a panel at this location?

If you are adding more than 3 locations, please use one of the bulk add templates at the top of the page.

Practitioner Application (One Health Port or CAQH)

Practitioner application filled out in One Health Port or CAQH (if no, only move forward if credentialing for this specialty or provider type is not required)?
A current, attested WPA is required. WPA attestations expire every 180 days. Attestation cannot expire during the enrollment and credentialing process.
HCA requires that providers who contract with Managed Care Organizations register in the state’s ProviderOne (Washington state’s Medicaid Information System). Practitioners either need a Core Provider Agreement or register as a non-billing provider.
Example CRNP or RN
Ensure proper format according to state licensing board(s). Example: WA = 2 alpha, 8 digits
Multiple languages should be separated with a comma and are intended to reflect the individual practitioner rather than office or clinic staff language ability. The response must provide enough information for an enrollee looking for a provider to know whether he or she speaks the enrollee’s language or how to access interpreter services.
Specialties should be determined by, and consistent with Taxonomy and/or the disciplines (Family Medicine, Geriatrics, OB, Surgery) in which they are actively practicing.
Assign appropriate Taxonomy based on practitioner type. Do not assign a location/clinic/center Taxonomy to an individual practitioner.
Practitioner Primary Specialty Board Status * Indicate the board status of the practitioner as it relates to their secondary specialty/taxonomy.
The organization that provided board certification for the practitioner in this specialty.
Practitioner Secondary Specialty Board Status
The organization that provided board certification for the practitioner in this specialty.
Hospital based? *
Example: Female Only, Male Only, None, Pregnant Women Only
No Blanks. Indicate age range restrictions: 18 & Younger, 19& older, 65 and Over, etc. or None if no age restrictions are present
Telemedicine Services * Indicate whether practitioner provides services to members/patients via telemedicine. Telemedicine is when a health care practitioner uses HIPAA-compliant, interactive, real-time audio and video telecommunications (including web-based applications) or store and forward technology to deliver covered services that are within his or her scope of practice to a client at a site other than the site where the provider is located.
For More details - please reference the Washington Administrative Code: WAC 182-531-1730 and HCA guidance
RCW 48.43.007(2) - Provider's Education. Medical School, etc. as required for Ambetter providers
Cultural competency, or the ability of health care providers to work effectively with colleagues and patients in cross-cultural situations, is a vital component of professional competence.

Final Comments and Contact Information