Policies & Fee Schedules

Claims

Our excellent claims review programs and strategic partnerships with pharmacy and vision vendors allow our claims information to be loaded into our system in a timely manner. We are 100 percent paperless within 24 hours. Our strong business practices are complemented by the addition of essential tools for managing medical expenditures. We have access to secondary networks on a national basis for out-of-network discount negotiations.

Unmonitored claims can rise quickly. We are committed to using cost containment programs actively for all clients from the beginning before they escalate.

The Health Plan may require additional documentation in order to adjudicate your claims to assist with the submission of required documentation, such as an operative report for multiple surgical procedures, or office notes if the diagnosis does not support the level of service billed. Fax the required documentation to 740.699.6163.

To assure 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 your claim(s) 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. This cover sheet can be found on THP's secure provider portal at myplan.healthplan.org


Claims Submission and Reconsiderations

We utilize the 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 30 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 were 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 365 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 365 days from the DOS, whichever is greater. Exceptions, if any, are noted in the agreement with The Health Plan.

The Health Plan provides tools to evaluate your claims during processing. We provide an in-process claims list on the 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. Healthcare services rendered to our members may be submitted to The Health Plan on either the CMS-1500 for professional (provider) claims or on the UB-04 claim form for facility services unless submitted electronically.


Electronic Claims Voucher

The Health Plan provides the HIPAA 835 transaction set for electronic vouchers. The electronic vouchers are produced with all lines of business on a daily basis as payments are released. Self-Funded payments are released at the direction of the self-funded employer group administrators. Claims for Commercial, Medicare Advantage, WV Medicaid, and PEIA are released on Wednesday mornings for providers and on Friday mornings for facilities.

If you are currently utilizing a clearinghouse or a registered submitter to The Health Plan, simply contact your submitter/clearinghouse to set up the retrieval of the electronic vouchers for your organization. The list of trading partner/clearinghouses provides the payor ID.

Click here to download our preferred clearinghouse list. 

If you are NOT currently using a clearinghouse or registered submitter for The Health Plan, please complete a Trading Partner Form and email it to the EDI Support Center at hpecs@healthplan.org. Once received, The Health Plan will set up the electronic voucher to be sent to your designated location by Internet or FTP. The setup information will include file names, submitter ID, sign on and password for Internet or FTP. This form can be accessed by logging in to your Secure Provider account at myplan.healthplan.org

Provider/facilities set up for ERA electronic vouchers will continue to receive their paper vouchers for six months after the receipt of three successful ERA. If you wish to extend the standard six months, please notify the EDI Support Center in writing. We also have a form available for these requests. Paper vouchers will be discontinued for existing provider/facilities unless a request for an extension is received. The vouchers are located on the Secure Provider website for you to access and download at your convenience.

If files or reports are missing or requiring status, the clearinghouse or submitter is to contact the EDI Support Center via email with all details to assist in their location. Responses for these emails will be within 24 to 72 business hours in most cases.


Fee Schedules

Click the links below to be redirected to the appropriate fee schedules:


Member Rights & Responsibilities