EDI Claims for AHC Network Affiliates

One of the most critical functions in a provider’s office is insurance claims submission. ActivHealthCare (AHC) understands the importance of this task and is here to help you manage your outstanding insurance receivables. AHC will assist you with your EDI claims and will continue to work on your behalf to resolve all outstanding insurance claims.

The steps for claims processing are as follows:

Step 1 Verify patient’s insurance coverage through the insurance payor. Be sure to verify that you are listed in the PPO network, if applicable.
Step 2 Determine if the patient's insurance is listed in the network affiliates or employer lists. If this is not an in-network claim, view the instructions for filing out-of-network claims.
Step 3 Thoroughly complete the health insurance claim form in your management software program. This form is often referred to as a HCFA1500 or CMS-1500. Be sure to pay attention to the requested information. View specific CMS-1500 instructions and common mistakes in completing this form.
 
Step 4 Include the name and address of the insurance payor in the blank area of the upper right hand corner (above box 1a) of the CMS-1500 form.
  If this is a claim for one of the AHC network affiliates, complete the payor information in the following format:
           AHCØ1 Insurance Payor’s Name
           Insurance Payor’s Street Address or P.O. Box
           Insurance Payor’s City, State & Zip Code

  Obtain the insurance payor’s information from the insurance identification card. Do NOT put ActivHealthCare as the payor name and address, except for Coventry HMO claims. If AHC is listed as the payor name then Office Ally will not know where to send your claim for payment. By placing AHCØ1 as a prefix to the insurance payor’s name, Office Ally will know how to direct this claim for payment. This format will expedite the processing of your claims by providing AHC with the payor’s address on the CMS-1500.

Step 5 In addition, a pin number is required in box 33 of the CMS-1500. This is the pin provided to you by the payor. If the payor does not require a pin, then use the provider’s federal ID number. If this box is left blank, the claim will be rejected by Office Ally.

Step 6 Once the claim information has been completed, print the claim “to file” according to your software specifications. You will need to know where to find this file on your computer. Office Ally will train you to upload this file electronically. You will receive an upload confirmation by email. You will then be able to monitor the status of the claim online.

Step 7 In most cases the insurance claims payor will process the claim and send AHC an explanation of benefits within 30 days. We will promptly process the claim through our system and issue a bulk pay remittance to you summarizing all claims processed for your office during the week.

Step 8 In some cases, the carrier may not process a claim promptly. If the carrier needs additional information, they may respond to you directly or to AHC. If they request the information from AHC, we will relay that request to you. AHC will continue to follow up on the claim until it is resolved.

There are three situations where a payor might be shown on a CMS-1500 in different ways.

  • If the patient is insured with NovaNet, an AHC network affiliate, as identified on their insurance identification card and box 11c of the CMS-1500, then the payor would be entered on the CMS-1500 with the AHCØ1 prefix in front of the payer name as shown in Example 1. In this example, Aetna is the payor for NovaNet (from box 11c). Therefore, the payor is identified on the top of the CMS-1500 as AHCØ1 Aetna, with the mailing address from the insurance identification card. If the insurance card has the mailing information to NovaNet, then the payor would be AHCØ1 NovaNet as shown in Example 2.

  • The exception to the first situation is Coventry HMO. All Coventry HMO claims should identify the payor as AHCØ1 ActivHealthCare with AHC’s address as shown in Example 3. If the patient is insured with Coventry, as identified on their insurance identification card and box 11c of the CMS-1500, you must call AHC to determine if they are Coventry HMO. If they are insured by the HMO, include the AHCØ1 prefix with the ActivHealthCare name and address as the payor as shown in Example 3. All other Coventry claims should be filed as shown in Example 2.

    Note: Any payors that also provide third-party administrative services or pays claims for employer groups and patients affiliated with AHC will necessitate that you set up the payor two times in your management software. One would be AHCØ1 Payor name and secondly, (no AHCØ1 prefix) Payor name. Examples 1 and 4 show the same payor set up in two different ways. The claim's mailing address may or may not be the same. This information would be provided on the patient’s insurance identification card.

Failure to properly identify the payor information at the top of the CMS-1500, will most likely result in your claim being processed out-of-network, creating additional work for your office staff and patients.

In order to avoid delays in payment, it is very important that you have your insurance carrier database set up correctly in your claims management software.