Running an AFH · For owners & operators

Getting Paid: ProviderOne Billing, Client Responsibility and Specialty Contracts

How a Washington adult family home gets its Medicaid contract, bills ProviderOne, collects the resident's share, and qualifies for specialty designations and ECS or SBS contracts.

Written from the HCA, DSHS and Washington rules it cites, checked October 12, 2026. Its primary sources are listed under the author note at the end of the page.

Step one: the Medicaid contract

A license lets you operate. It does not let you bill Medicaid. DSHS says contractors "cannot admit new Medicaid clients until they have a signed Medicaid contract in place."

DSHS posts the steps for a licensed home:

1. Email the DSHS Contracts Unit at adshqcontracts@dshs.wa.gov asking for a Medicaid contract. Give the home's name, license number and address. (DSHS's licensing FAQ also lists the AFH Contracts Manager at 360-725-2649, for adding or ending a Medicaid contract.)
2. Return the forms DSHS sends (or send them with your request): the Contractor Intake Form (DSHS 27-043), "Additional Details AFH," the Medicaid Provider Disclosure Statement, and a W-9.
3. Review, sign and return the contract the contract manager emails you.
4. DSHS sends back the fully signed contract with your ProviderOne number. HCA then emails login instructions. If none arrive within 24 hours, call HCA at 1-800-562-3022.

The DSHS sample contract also requires trained, background-checked staff and liability insurance of at least $1,000,000 per occurrence and $2,000,000 in total. The posted sample is an older version, so read the contract DSHS sends you. The contract ends "on the effective date of a change in licensee," so a buyer needs a new one. See Buying or Selling an AFH.

Step two: the authorization

DSHS pays "only for authorized services." The resident's DSHS case manager authorizes services based on the CARE assessment. You see each authorization in ProviderOne on the "Social Service Authorization List," with the case manager's name and email.

If an authorization is in "Error" or "Canceled" status, HCA says you "MUST contact the client's case manager before providing or billing for services." DSHS tells case managers the authorization "should be entered/complete prior to the client being admitted." Billing questions go to HCA at 1-800-562-3022; authorization questions go to the case manager.

Step three: billing in ProviderOne and when you are paid

You submit claims in ProviderOne by direct entry, saved templates, batch templates (useful for the same residents every month) or a clearinghouse upload. What HCA says about timing:

• Payment cycle. "ProviderOne makes weekly payments." Claims submitted by Tuesday at 5 p.m. Pacific "should pay the same week on Friday at the earliest or the following Monday at the latest." Holidays and system maintenance can move these dates.
• Late in the week. A claim entered after the Tuesday deadline pays on Friday of the next week.
• Timely filing. "Providers must submit claims no later than 12 months from the date of service." The DSHS contract says the same.
• Remittance advice. A weekly remittance advice (RA) listing paid, denied, adjusted and in-process claims is posted each Friday.
• Checks or direct deposit. New social service providers are set up for paper checks (warrants) by default. You must sign up separately for electronic funds transfer (EFT).

Part months are prorated, and DSHS "does not pay for the last day of service if a client moves out," except on the date of death.

The resident's share: client responsibility

Most Medicaid residents pay part of the monthly cost themselves. ProviderOne calls this client responsibility. HCA defines it as "the amount a client must pay to the provider each month." It has up to three parts:

• Room and board: what the resident pays for food and shelter. The rules say "Room and board is not participation."
• Participation: what the resident pays toward the cost of care.
• Third-party resources: other money owed toward care.

Who calculates it. You do not. The DSHS contract defines participation as "the amount determined by ALTSA/HCS financial services" (the Aging and Long-Term Support Administration's Home and Community Services). For a resident on a home and community based waiver, WAC 182-515-1509 says the resident keeps a personal needs allowance, pays room and board up to a state standard, and pays the rest of their available income toward care after allowed deductions, such as guardianship fees or support for a spouse at home. A resident on Community First Choice (CFC) without a waiver keeps a personal needs allowance and pays room and board, but the participation calculation does not apply (WAC 182-513-1215). Either way, the amount is set by DSHS, not by you. Check each resident's client responsibility in ProviderOne before you bill, and again whenever DSHS tells you an amount has changed.

How it reduces your payment. HCA: "ProviderOne will automatically deduct applied CR from paid claims," and "the provider must still collect this amount from the client each month." Medicaid pays the authorized rate minus the resident's share. You collect the share yourself.

Payment in full. The Medicaid payment plus the participation DSHS assigns "is payment in full" for services in the resident's service plan (WAC 388-105-0050). You may not charge a Medicaid resident extra for anything the daily rate covers. The same rule allows a supplemental payment only for items not covered by the Medicaid rate, and only if you first have a written supplemental payment policy given to applicants and residents, record each payment in the resident's file, and notify the case manager. When a resident moves out, DSHS guidance says to refund unspent participation within 30 days.

Your Medicaid policy. Every home must give prospective residents a separate written policy on when it accepts Medicaid (WAC 388-76-10522).

When a resident does not pay

ProviderOne deducts the resident's share whether or not the resident pays you. DSHS's "Non-Payment Frequently Asked Questions" flyer for residential providers says:

• "As soon as you learn of non-payment promptly email the Home & Community Services (HCS) Case Manager (CM)." Put [Secure] in the subject line.
• Find out why. The case manager can meet with the resident and family, and help arrange a representative payee or a payment plan.
• If you suspect financial exploitation, you are a mandated reporter. Report it to DSHS.
• "Do not wait until the client is several months in arrears to take action."

Nonpayment is a lawful reason for discharge (WAC 388-76-10615), usually with at least 30 days' written notice (RCW 70.129.110). For a Medicaid resident, the notice has required content, including the resident's right to a free lawyer, and you must send copies to the case manager and the long-term care ombudsman within three calendar days of issuing it (WAC 388-76-10617). DSHS also asks for form 05-249 to be sent to the case manager.

Specialty designations: dementia, mental health and developmental disabilities

DSHS "may designate an adult family home to provide specialty care" in developmental disability, mental illness and dementia (WAC 388-76-10495). DSHS grants the designation when (WAC 388-76-10500):

1. The provider, entity representative and resident manager have completed the specialty training;
2. The home sends DSHS written proof of that training (or challenge test) and of specialty training for all caregivers; and
3. The home meets each resident's specialty needs.

A home "must not admit or keep a resident with specialty care needs" unless the provider, entity representative, resident manager and staff have completed the specialty training in chapter 388-112A WAC (WAC 388-76-10505). There is one window: if a resident who already lives in a home without the designation develops one of these needs, the provider, entity representative and resident manager have 120 days to complete the specialty training (WAC 388-112A-0490; RCW 70.128.230). The window does not apply to admitting a new resident who already has the need. How to ask for it. DSHS's licensing FAQ says a licensed home adds a specialty designation by sending a complete, signed and dated AFH Information Change form (DSHS 10-585). See Training & Education for the courses. These rules do not attach a payment rate to a designation.

ECS and SBS: specialty contracts on top of the Medicaid contract

Both are services under the Residential Support Waiver (RSW), a Medicaid program for adults with complex behavioral or psychiatric histories and no other placement option (WAC 388-106-0338). DSHS awards them to "currently contracted AFH/AL providers who meet provider requirements."

Expanded Community Services (ECS) covers personal care, 24-hour on-site support, medication management and behavior support. It "does not offer 1:1/enhanced staffing."

Specialized Behavior Support (SBS) adds "six to eight hours a day of individualized staff time" (WAC 388-106-0336). The home needs an approved staffing calendar before SBS is authorized, and "may only serve up to three SBS residents at any given time." The HCS Regional Administrator may approve one more, to a maximum of four.

Who qualifies, from DSHS's pages:

• A current AFH Medicaid contract held for at least 12 months. (DSHS's case-management manual says a license held 12 months instead. AFH Club has asked DSHS which applies; a home with 12 months under contract meets both.)
• No significant enforcement actions by Residential Care Services in the last year.
• ECS or SBS contract training, given by DSHS's Regional Resource Specialist, completed before the contract.
• For SBS, a "demonstrated history" of working with residents with challenging behavior.

CBHS comes first. For care plans from assessments on or after July 1, 2025, a resident must first be found not eligible for Community Behavioral Health Support (CBHS) before getting SBS (WAC 388-106-0336). DSHS's manual says existing SBS residents moved to CBHS at their next annual or significant-change assessment between July 1, 2025 and June 30, 2026. ECS does not require a CBHS referral. See CBHS Tiers.

How to apply. DSHS Resource Development told AFH Club in writing (October 12, 2026) that an AFH owner can reach out to Resource Development (ResourceDevelopment@dshs.wa.gov) or to the home's assigned Home and Community Services residential case manager. The contract training comes from DSHS's Regional Resource Specialist and must be finished before the contract is issued.

What about the rates?

Daily base rates, CBHS tier rates and ECS and SBS amounts are in the Payment Field Guide and A Through E, with sources and dates.

What to do next

• Email adshqcontracts@dshs.wa.gov for your Medicaid contract as soon as your license is issued, and sign up for EFT in ProviderOne.
• Before each Medicaid admission, confirm with the case manager that the authorization is active, and check the client responsibility amount in ProviderOne.
• Write your Medicaid policy (WAC 388-76-10522) and a simple monthly process for collecting each resident's share.
• Plan specialty training before you accept residents with dementia, mental illness or developmental disabilities: Training & Education.
• Understand how the money stacks: Payment Field Guide, CARE Classifications, CBHS Tiers.
• Taxes on that income: Do Adult Family Homes Pay Taxes?.