Claim Submissions
Please submit claims for processing in a HIPAA-compliant 837 file format and file them electronically with
Healthcare providers should work with their practice management system, system vendor or billing service to ensure CarePlus Health Plans is enabled for electronic claim submission. If unable to submit electronically, providers can submit professional claims on a properly completed CMS 1500 form within the time frame specified in their contracts. Providers may use the revised 1500 claim form (version 02/12). This approved, updated 1500 claim form accommodates reporting needs for ICD-10 and aligns with requirements in the Accredited Standards Committee X12 (ASC X12) Health Care Claim: Professional (837P) Version 5010 Technical Report Type 3.
If unable to submit facility claims electronically in 837I file format, providers can submit them on a properly completed UB-04/CMS 1450 form within the time frame specified in their contracts.
If all electronic data interchange (EDI) methods fail, and you’ve already contacted your provider services executive for assistance, mail the paper claim submission and claim-related correspondence to the following address:
CarePlus Health Plans
Attn: Claims Department
P.O. Box 14697
Lexington, KY 40512-4697
Not submitting a clean, properly completed claim will delay processing. CarePlus’ contracted provider filing limitation is 180 days from the date of service or the through-date of service listed on the claim form, whichever is the later date. The non-contracted provider filing limitation is 12 months from the date of service or the through-date of service listed on the claim form, whichever is the later date.
Participating provider grievances and requests for claims reconsiderations
Participating providers can submit a complaint to CarePlus to express dissatisfaction with the plan or to request reconsideration of a claim denial or payment amount.
Requests for Review of Denied Claims:
To request a review of service or claim payment denials by the Plan, providers can call the CarePlus provider services queue at 1-866-313-7587 (the number that is listed on the back of the Member’s ID card) or send a written request to the CarePlus Claims address at P.O. Box 14697, Lexington, KY 40512-4697.
Provider Claim Reconsideration Process:
If a provider disagrees with CarePlus’ initial review determination (conveyed via electronic or paper remittance advice) and would like to request a reconsideration/reopening of the issue, the provider can do so by writing to CarePlus at:
CarePlus Correspondence
P.O. Box 14697
Lexington, KY 40512-4697
When submitting a written request for reconsideration/reopening, providers must include the following information: provider name and tax ID, patient’s name and identification number, date of service, relationship of the member to the patient, claim number, name of the service provider, charge amount, payment amount and a brief description of the basis for contestation. Providers should be sure to include relevant supporting documentation (medical records, copy of invoice, etc.) with their request.
If a provider has a grievance regarding any aspect of CarePlus operations, the provider should first contact his or her designated provider services executive to discuss the matter. In the event a provider wishes to submit a formal grievance or request a second-level review of a previously reviewed claim denial or payment dispute, the provider must document the circumstances in writing and forward the explanation to his or her designated provider services executive at:
CarePlus Health Plans, Inc.
Attention: Provider Operations department
P.O. Box 277810
Miramar, FL 33027
The letter will be reviewed by the provider operations department and other plan departments, as required, to make a determination. A response will be sent within 60 days after receipt of the provider’s letter.
Note: The above provisions of this section are to be considered as separate and distinct from the arbitration provisions set forth in the provider’s agreement.
Important Note for Delegated Providers:
Claim issues or provider disputes must be submitted directly to the delegated entity and reviewed in accordance with the delegated entity’s claim resolution process. For additional details, please refer to the delegated entity you are affiliated with and/or your participating provider agreement with said entity.
Electronic Data Interchange (EDI) Corrections and Reversals
The 837 TR3 (Technical Report Type 3) defines the values submitters must use to signal to payers that the inbound 837 contains a reversal or correction to a claim that was previously submitted for processing. For both professional and institutional 837 claims, the 2300 CLM05-3 (claim frequency code) must contain a value from the National UB Data Element Specification Type List, Type of Bill and Position 3. Values supported for corrections and reversals are:
- 7 = Replacement of prior claim
- 8 = Void/cancel of prior claim
- Q = Reopening for institutional claim only
The following coding must be used:
Loop 2300
Segment CLM05-3 = 7
Segment REF01 = F8
Segment REF02 = the 13-digit original claim number – no dashes or spaces
If submitting via paper:
Professional corrected claims or voided claims that have a 7 or 8 in Box 22 should include the original claim number in the ORIGINAL REF NO field. When a 7 code populates in Box 22, the new claim will follow the replacement-of-prior-claim process. When an 8 code populates in Box 22, the new claim will follow the void/cancellation of the prior claim process.
Institutional corrected claims or voided claims that have a 7 or 8 in Box 4 (type of bill) should include the original claim number in Box 80 REMARKS. When the applicable frequency code is populated, the new claim will follow the applicable correction or void process. The number 7 represents replacement of prior claim; the number 8 represents a voiding or cancellation of a prior claim.
For institutional claims only, when the need for a correction is discovered beyond the claim’s timely filing limit of one year, an institutional provider must utilize the reopening process using the new bill-type frequency, submitting with a Q in Box 4 (Type of Bill) to identify it as a reopening. The provider also should include a series of condition codes that can be used to identify the type of reopening being requested. Reopenings for “good cause” must have a remark/note from the provider.*
*Institutional providers can request a reopening for any reason within one year from the date of the original determination or redetermination. Providers also may request a reopening for “good cause” within four years from the date of the original determination or redetermination. Good cause exists when:
- There is new and material evidence that was not available or known at the time of the determination or decision that may result in a different conclusion; or
- The evidence that was considered in making the determination or decision clearly shows that an obvious error was made at the time of the determination or decision.
