Claims and Billing

Submit claims through electronic data interchange (EDI) for faster, more efficient claims processing and payment. AmeriHealth Caritas DC EDI payer ID number is 77002.

Electronic claims may be submitted via

Availity

• Providers or clearinghouses not currently using Availity to submit claims must register at Availity.
• Providers who are currently registered with Availity for another payer, or using another clearinghouse, must request to have electronic claims for AmeriHealth Caritas DC routed to Availity.
• For registration process assistance, submit the Provider Inquiry form at the bottom of the Availity webpage or contact Availity Client Services at 1-800-AVAILITY (282-4548). Assistance is available Monday through Friday from 8 a.m. to 8 p.m. ET.

Optum/Change Healthcare

• AmeriHealth Caritas DC has reestablished connectivity with Optum/Change Healthcare.
• Providers who have a software vendor or use another clearinghouse to submit claims to Optum/Change Healthcare will need to consult with their vendor/clearinghouse to see if there have been changes in their process for claims submission.
• For questions contact Optum/Change Healthcare’s call center at: 1-800-527-8133, Monday through Friday from 8 a.m. to 8 p.m. CT.

Providers may submit manual/direct entry claims (at no cost) via:

Optum/Change Healthcare ConnectCenter™

This option is currently only available for providers who were registered with ConnectCenter prior to the security incident. It is not necessary to complete a new registration, and usernames will remain the same. Providers will be notified when the option for new registrations is reinstated.

To reconnect:

• Access the portal via the Claims submission link in the NaviNet provider portal or via one of these direct links:
  • ConnectCenter at Change Healthcare
  • Physician ConnectCenter at Change Healthcare
• Follow the instructions on the login page to reset your password and to set up the required multifactor authentication.
• For more information on available functionality, please review the release notes in the Product News section after signing into the ConnectCenter portal.
• Optum/Change Healthcare also provides helpful user guides to assist providers with navigating the ConnectCenter portal. To access the user guide, visit the Claims resources section at the bottom of this page.

PCH Global

To enroll for claims submission through PCH Global please go to: PCH Health Global

• Click the Sign-Up link in the upper right-hand corner.
• Complete the registration process and log into your account. You will be asked how you heard about PCH Global; select Payer, then AmeriHealth. Access your profile by clicking on Manage User and then My Profile. You will need to complete all the profile information. When you go to the Subscription Details screen, select the More option on the right-hand side to see how to enter the promo code Exela-EDI.
  
  
• When you are ready to submit claims, use the following information to search for our payer information:
  
  
  • Payer name: AmeriHealth
  • P.O. Box:
    AmeriHealth Caritas District of Columbia
    Attn: Healthy DC Plan Claims
    P.O. Box 7341, London, KY 40752
    

For a detailed walk-through of the registration process, refer to the PCH Global Registration manual (PDF), found on the PCH Global website in the Resource Menu.

Send paper claims to:

AmeriHealth Caritas DC is accepting ANSI 5010 ASC X12 275 claim attachment transactions (unsolicited). Please contact your Practice Management System Vendor or EDI clearinghouse to inform them that you wish to initiate electronic 275 claim attachment transaction submissions for payer ID 77002 via:

• Availity

  There are two ways 275 claim attachments can be submitted:

  • Batch — You may either connect to Availity directly or submit via your EDI clearinghouse.
  • Portal — Individual providers may also register online to submit attachments.

  After logging in, providers registered with Availity may access the Attachments — Training Demo Opens a new window for detailed instructions on the submission process Opens a new window or refer to the reference guide located under Claims Resources at the bottom of this page.

• Optum/Change Healthcare

  There are two ways 275 claim attachments can be submitted:

  • Batch — You may either connect to Optum/Change Healthcare directly or submit via your EDI clearinghouse.
  • API via JSON — You may submit an attachment for a single claim.

  View the Optum Change Healthcare 275 claim attachment transaction video Opens a new window for detailed instructions on this process.

General guidelines

• A maximum of 10 claim attachments are allowed per submission. Each attachment cannot exceed 10 megabytes (MB) and total file size cannot exceed 100 MB.
• The acceptable supported formats are pdf, tif, tiff, jpeg, jpg, png, docx, rtf, doc, and txt.
• The 275 claim attachments must be submitted prior to the 837. After successfully submitting a 275 claim attachment, an Attachment Control Number will generate. The Attachment Control Number must be submitted in the 837 transactions as follows:
  • CMS 1500
    – Field Number 19
    – Loop 2300
    – PWK segment
  • UB-04
    – Field Number 80
    – Loop 2300
    – PWK01 segment

In addition to the Attachment Control Number, the following 275 claim attachment report codes must be used when submitting an attachment. Enter the applicable code in field number 19 of the CMS 1500 or field number 80 of the UB04.

To inquire about claim status, sign in to NaviNet and select Claims Status Summary under Administrative Reports. Provider Claim Services can also check the status of up to five claims via phone at 1-888-369-0247.

Requests for reconsideration may be submitted through the NaviNet Electronic Claim Inquiry feature. For detailed information on electronic claim inquiry submission, please see the NaviNet Claims Investigation Provider Guide (PDF).

If a claim or a portion of a claim is denied for any reason or underpaid, the provider may dispute the claim within 60 days from the date of the denial or payment. A telephone inquiry regarding payment or denial of a claim does not constitute dispute of the claim. Claim disputes must be submitted in writing, along with supporting documentation to:

AmeriHealth Caritas District of Columbia Healthy DC Plan
Attn: Formal Disputes
P.O. Box 7445
London, KY 40742-7445

If a provider is not satisfied with the resolution of a dispute they may seek a second-level review. A request for a second level review must be sent in writing within 30 calendar days of receiving AmeriHealth Caritas DC’s response to the initial review. We will send an acknowledgement letter within five business days of receiving your appeal. You will receive a response letter regarding your appeal within 30 calendar days of AmeriHealth Caritas receiving your appeal. If the claims denial is overturned, you will receive payment within 30 calendar days of the decision.

An appeal is a provider’s request to AmeriHealth Caritas DC to take another look at a previously denied claim.

• All first-level appeals must be submitted within 60 business days of the denial or payment.
• Providers must submit a written request for an appeal with the specific reason for the appeal and the appropriate supporting documentation (including a copy of the claim and Explanation of Benefits [EOB]).
• AmeriHealth Caritas DC will send an acknowledgment letter within five business days of receiving an appeal.
• Second-level appeals must be sent in writing within 30 calendar days of receiving AmeriHealth Caritas
• DC’s response letter. We will send an acknowledgement letter within five business days of receiving your appeal. You will receive a response letter regarding your appeal within 30 calendar days of AmeriHealth Caritas receiving your appeal.
• If the claims denial is overturned, you will receive payment within 30 calendar days of the decision.

If a Plan provider identifies improper payment or overpayment of claims from AmeriHealth Caritas DC, the improperly paid or overpaid funds must be returned to the Plan within 60 days from the date of discovery of the overpayment. Please include the enrollee’s name and ID, date of service, and claim ID.

Providers are required to return the improper or overpaid funds by:

AmeriHealth Caritas District of Columbia
Healthy DC Plan
Attn: Provider Refunds
P.O. Box 7341, London, KY 40742

AmeriHealth Caritas DC offers ERAs through ECHO Health, Inc. ECHO is a leading provider of electronic solutions for payments to healthcare providers. ECHO consolidates individual provider and vendor payments into a single compliant format, remits electronic payments and provides an explanation of payment (EOP) details to providers.

To receive ERAs providers will need to include both the Plan payer ID and the ECHO payer ID 58379. Contact your practice management/hospital information system for instructions on how to receive ERAs from AmeriHealth Caritas DC under Payer ID 77002 and the ECHO Payer ID 58379.

All ECHO Health-generated ERAs and EOPs for each transaction will be accessible to download from the ECHO provider portal. If you are a first-time user and need to create a new account, please reference ECHO Health's Provider Payment Portal Quick Reference Guide (PDF) for instructions.

If your practice management/hospital information system is already set up and can accept ERAs from AmeriHealth Caritas DC, it is important to check that their system includes both the Plan and ECHO Health Payer IDs.

If you are not receiving any payer ERAs, contact your current practice management/hospital information system vendor to ask if your software can process ERAs. Your software vendor is then responsible for contacting Optum/Change Healthcare to enroll for ERAs under 77002 and ECHO Health Payer ID 58379.

If your software does not support ERAs or you continue to reconcile manually, but would like to start receiving ERAs only, please contact the ECHO Health Enrollment team at 1-888-834-3511.