Claims and Billing Process. AHCCCS Provider Identification Number and NPI Number

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1 Claims and Billing Process AHCCCS Provider Identification Number and NPI Number All United Healthcare Community Plan providers requesting reimbursement for services must be properly registered with AHCCCS and have a valid AHCCCS Physician or Health Care Provider Identification Number. Physician or health care providers may register with AHCCCS by contacting AHCCCS physician or health care provider Registration Department at option 5, or option 5 (in Arizona) or (out of state) from 8 a.m. to 5 p.m. (MST) Monday through Friday. Claims submissions that are missing the National Provider Identification Number (NPI) numbers will be denied for payment. All providers are impacted with the exception of a few excluded providers such as housekeeping, home care, personal care, non-emergency transportation, adult day health care. To verify if you are a provider who is excluded, please use the link below: To complete this application process, providers can: 1. Go to: This is the fastest way to get a NPI number and ensures priority processing. 2. Call CMS to obtain a paper application at Send an to: Providers must communicate their NPI to health plans, clearinghouses, other providers and AHCCCS before the compliance date. UnitedHealthcare Community Plan Provider Services is starting to collect these numbers internally. If you have obtained your NPI number, please contact your Provider Services Representative. Providers can notify AHCCCS by: 1. ing AHCCCS at the mail box. This address can only accept copies of the statement mailed to the provider from the NPI enumerator. 2. Faxing a copy of the statement to Mailing a copy of the statement to: AHCCCS, Provider Registration Unit, and P.O. Box 25520, Phoenix, AZ 85002, Mail Drop 8100

2 Acceptable Claims Format Physicians and health care providers must submit their claims in one of the following formats: Electronic claims submission via a clearinghouse CMS 1500 UB-92 or UB-04 Free downloadable forms can be found on the CMS website at: Electronic claims submission offers providers confirmation receipts, faster and more efficient payment, less paperwork and lower mailing costs. UnitedHealthcare can accept electronic claims through our contracted claims clearinghouses. EDI/Electronic Claims Submission UnitedHealthcare Community Plan offers electronic claims submission for most of our contracted providers. Some of the benefits to filing your claims electronically are: You will receive an electronic confirmation of proof of receipt or notification if the claim is missing required information. Improvement of data integrity Decreased turnaround time on claims processing Decreased dual entry of claims by the provider Eliminate manual creation of claims by the provider Decreased response time on claim errors HIPAA compliant No more paper claim submissions or associated mailing costs Flexibility to submit claims any time Training and technical support JDA: Phone: Emdeon (Formerly Web MD/Medifax): Phone: , Option 3 for Sales Office Ally: Phone: Initial Claims Filing Time Limits United Healthcare Community Plan requires that all initial claims be submitted within 90 days following the date that the service is rendered, or the date of discharge. We are always the payer of last resort so you must bill any other insurance, including Medicare, first before submitting your claim to us. Claims involving coordination of benefits must be submitted within 60 days from the date of the Explanation of Benefits (EOB) from the primary and/or secondary payor.

3 Providers must attach a copy of the payor s EOB with your UnitedHealthcare Community Plan claim, even if the claim was originally denied. Please refer to your physician and health care Provider Agreement for further clarification as some contracts may have difference filing limits. Clean Claims A clean claim is a claim that has all the required fields filled out correctly and is legible. Claims that are not completely filled out or are illegible will be returned unprocessed to the provider and are not considered as received by UnitedHealthcare Community Plan. Claims that have inaccurate information in the fields will be processed and denied. The provider can resubmit a clean claim for processing. Where to Mail Claims UnitedHealthcare Community Plan is always the payer of last resort. Physicians and health care providers must bill any other health care insurance carrier that the patient is enrolled with prior to billing UnitedHealthcare Community Plan, including Medicare. Attach clear and legible documents such as medical records, primary EOB, invoice, or other items, if applicable. Resubmitting Claims United Healthcare Community Plan - LTC P.O. Box 30995, Salt Lake City, UT Providers have up to 12 months from the date of service or discharge date to resubmit their claim. All claims resubmissions should include at a minimum the following information: Paper format: Corrected claim form with Resubmission written on it or a Reconsideration Form Claim number written in box 22 Copy of the remittance advice from the denied claim Attach if applicable, a clear legible copy of the requested items such as medical records, primary EOB, invoice, or other documentation. Claims should be resubmitted to the UnitedHealthcare Community Plan claims address Electronic format: Utilize the online provider portal to Request for Reconsideration through Optum Cloud. Attach if applicable, a clear legible copy of the requested items such as medical records, primary EOB, invoice, or other documentation.

4 Coding Reference Manuals CPT code books are available at most book stores or can be ordered by contacting the American Medical Association at or The ICD-9-CM diagnosis code book can be found at most book stores or by contacting the American Hospital Association at or CMS 1500 claim forms may be obtained by contacting the American Medical Association at or UB92 claim forms may be obtained by contacting the American Medical Association at or Time Limits for Filing Appeals A physician or health care provider must submit any dispute challenging a claim denial or adjudication within 12 months (365 days) from the end date of service or date of discharge. For hospital claims or prior period coverage, the provider must submit any dispute challenging the claim within 12 months from the date of discharge or 12 months from the date of eligibility posting, whichever is later, or within 60 days after the payment denial or recoupment of a timely claim submission. Upon receipt, the Claim Dispute Coordinator will date stamp the request and that date will be considered the filing date for timeliness purposes. Escalation Process 1. Upon receipt of the denial or short payment EOB, provider may call customer service to dispute at or log onto and utilize the Optum Cloud to resubmit the claim through the reconsideration process. The provider will receive a tracking # for their inquiry. Please allow 30 days for a resolution. 2. If there is no resolution in step one, please have your tracking number ready and contact your provider representative. 3. Your provider representative will notify you if this can be corrected internally or if an appeal must be filed. Appeals Process Please follow these steps to ensure proper review of your dispute: 1. Submit a cover letter indicating why you think your claim should not have been underpaid or denied. Please include the following: The date you wrote the letter Details of the reason for the dispute and your outcome/resolution expectations Any documentation supporting the facts such as medical records, primary EOB,

5 invoice, or other applicable documents. The patient s AHCCCS ID number, name, and date of service The appeal submitter s signature 2. A typed letter is preferred, however if you choose to handwrite your letter, please be sure it is legible. 3. Please use letterhead or include a correspondence address on your letter so we know where to send the response resolution letter. 4. Include with the letter, if available: A copy of the provider remittance advice (PRA) from UnitedHealthcare Community Plan - LTC A copy of the original claim A copy of the Medicare EOB (if applicable) A copy of the authorization (if applicable) A copy of medical records (if applicable) If you are a contracted provider and have specific rates associated with your contract, please include a copy of the rates page of your contract. 5. Mail the letter and attachments to: United Healthcare Community Plan - LTC Attn: Grievance Coordinator 1 E Washington Street, Ste 800 Phoenix, AZ Upon receipt of an appeal, UnitedHealthcare Community Plan will mail an acknowledgement to the party identified on the request that should be kept for future reference. Upon investigation, UnitedHealthcare Community Plan will issue the provider a decision notice or request additional information and/or an extension. If we make a decision on the same day we open your dispute, both letters may be included in the correspondence. If the UnitedHealthcare Community Plan decision is favorable and requires a payment adjudication to the claim, your claim will be sent for processing and your payment will be mailed to you within 15 business days in a regular PRA. If the physician or health care provider receives a denial resolution decision letter, the provider will have 30 days from the postmark to request, in writing to the UnitedHealthcare Community Plan Grievance Coordinator, a state fair hearing. The provider must reference the dispute number and indicate that a request for state fair hearing is being filed. Further instructions are outlined in the decision letter or in the Provider Manual.

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