Claims

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 740.695.7882.

To assure the required documentation is routed correctly, you must accurately complete the "Health Plan 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.


ICD-10 Information
The ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by the ICD-10 code sets. The ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by the Health Insurance Portability Accountability Act (HIPAA). This is not limited to those who submit claims to Medicare or Medicaid or who are using electronic submissions of data.

The ICD-10 is mandated for October 1, 2015, and all services billed, including paper or electronic, must use the ICD-10 codes. Any claims with dates of service October 1, 2015, and after must have ICD-10 codes. ICD-9 codes are still to be used on claims prior to October 1, 2015.

We recommend all healthcare providers use the cms.gov website for their ICD-10 questions and The Health Plan will be following these same guidelines. We will publish and update each quarter any information regarding the ICD-10. We hope to be useful during your implementation.


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 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 for the UB-04 claim form for facility services unless submitted electronically.