Claims


The Health Plan is 100 percent paperless within 24 hours because of our excellent claims review program and strategic partnerships with pharmacy and vision vendors. Our strong business practices are complemented by the addition of essential tools for managing medical expenditures and we have access to secondary networks on a national basis for out-of-network discount negotiations.

We understand unmonitored claims can rise quickly and The Health Plan is committed to using cost containment programs for all clients from the beginning before they escalate. We sometimes require additional documentation in order to adjudicate claims. Documentation required may include an operative report for multiple surgical procedures or office notes if the diagnosis does not support the level of service billed.


Claims Submission and Reconsiderations

We utilize established state and federal guidelines for releasing of claims. The Health Plan’s claim number houses the date of receipt of a claim and the claim will release before 30 days after receipt. This is the receipt of the claim and not the date of service. Health care providers should allow 45 days from the date of submission to inquire about the outcome. The Health Plan’s vouchers, either paper or electronic, will provide the status of the claim after the 30 days and should be used prior to inquiring on the claim(s).

Time limits for submitting claims have been established by The Health Plan in its continuing efforts to better manage health care costs. The original claim must be received by The Health Plan 180 days from the date of service. In the event the claim requires resubmission, health care providers have 180 days from the date of the original denial or 180 days from the DOS, whichever is greater.

The Health Plan provides an in-process claims list on payment vouchers, a secure provider portal listing claims status, and a customer service area to handle telephone inquiries. Claims denied for timely filing must have an explanation for the delay as well as specific documentation. The Health Plan encourages electronic claims submission, however, providers submitting paper claims must use original claim forms (red ink) when submitting either the CMS-1500 for professional (provider) claims or on the UB-04 claim form for facility services unless submitted electronically. Handwritten claims are not acceptable and will be rejected.

Providers may submit documentation to support an electronic claim. To ensure the required documentation is routed correctly, you must accurately complete The Health Plan's fax cover sheet in its entirety. Failure to complete the fax cover sheet may result in a claim being denied. A separate fax cover sheet is required for each claim or service faxed. You must fax all required documentation within 24 hours of your electronic claims transmission. The fax cover sheet is available here. Providers are asked to fax the required documentation to 740.699.6163.


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