VCHCP will accept claims from contracting providers if they are submitted within 180 calendar days (or the timeframe specified in the contract, if greater) after the date of service. Non-contracted provider claims will be accepted if they are submitted within 180 calendar days after the date of service. If VCHCP is not the primary payer under coordination of benefits (COB) rules, the claim submission period begins on the date the primary payer has paid or denied the claim. Claims not received within the timely filing period will be denied.

Providers have an obligation to be responsible for appropriate timely billing practices. Provider requests to review a claim for timeliness following denial because the provider believes there was good cause for the delay will be handled as a Provider Appeal.

If a claim is denied for timely filing but the provider can demonstrate "good cause for delay" through the provider dispute resolution process, VCHCP will accept and adjudicate the claim as if it had been submitted within the provider's claim filing timeframe.

Good cause for untimely submission of claims:

• Patient gave incorrect health coverage/insurance information (e.g., copy of an incorrect ID card);
• Patient was unable to provide health coverage/insurance information (patient was comatose, the patient expired before the information could be obtained, etc.);
• Natural disaster/acts of nature (fire, flood, earthquake, etc.);
• Acts of war/terrorism;
• System-wide loss of computer data (system crash).

Examples of circumstances that do not constitute "good cause":

• Claim was sent to the wrong carrier (Blue Cross instead of VCHCP), but the provider had the correct health plan coverage/insurance information on file and did not attempt to follow up on the account to file to the plan in a timely manner;
• The claim was submitted timely, but VCHCP was unable to process it because the claim was not a complete claim (it did not contain the minimum data elements to enter the claim into the system (i.e., missing a subscriber number);
• The claim was not submitted timely and the provider cannot provide a reason to explain the delay, or provide supporting documentation in order to support the delay.

Paper Claim Submission:

All paper claims and supporting documentation must be submitted to:

Mailing Address:

Ventura County Health Care Plan
Claims Processing Department
2220 E. Gonzales Road, Suite 210B
Oxnard, CA 93036

Electronic Claim Submission:

Providers may submit their claims electronically through Office Ally, a claims clearinghouse, at no charge. For information regarding how to contact Office Ally, you may call the VCHCP Member/Provider Services Department at (805) 981-5050, contact Office Ally directly at (360) 975-7000, or visit their website at www.officeally.com.

Refer to the HIPAA ANSO Implementation Guide and California 837 Transaction Companion Guide for the specific regulatory requirements for submitting claims electronically.

A complete claim is a claim or portion of a claim, including attachments and supplemental information or documentation that provides reasonably relevant information necessary to determine payer liability that may vary with the type of service or provider. Reasonably relevant information means the minimum amount of itemized, accurate and material information generated by or in the possession of the provider related to the billed services that enables a claims adjudicator to determine the means the minimum amount of material information in the possession of third parties related to a provider's billed services that is required by a claims adjudicator to determine the nature, cost, if applicable, and extent of the plan's liability, if any, and to comply with any governmental information requirements. In addition, the plan may require additional information form a provider where the plan has reasonable ground for suspecting possible fraud, misrepresentation or unfair billing practices.

In general, VCHCP uses Medicare guidelines such as those found in the Medicare Claims Processing Manual and Medicare Fee Schedule section contained within the Medicare Compliance Manual published by PMIC for processing provider claims.

When submitting claims all providers must include, at a minimum, all of the required information:

-Patient's ID number
-Patient's name and date of birth
-Submitting provider's tax ID number or Social Security number
-National Provider Identifier (NPI) of attending and referring providers
-Submitting provider's name and address
-ICD-9 (service dates prior to 10/1/2015) or ICD-10 diagnosis code(s) for dates of service after 10/1/2015
-Service date
-Billed charge
-Current CPT or HCPCS procedure code (physician) or UB-04 revenue code with narrative description (hospital/institutional)
-Submitting provider's name and address
-CMS place of service code (professional claims only)
-CMS type of service code (professional claims only)
-Number of days or units for each service line (UB-04 and professional claims)
-When authorization is required include authorization number and all necessary information

Additional information required for select providers includes:

-Dentists and other professionals providing dental services: The form and data set approved by the American Dental Association (ADA), Current Dental Terminology (CDT) codes and modifiers, and any state-designated data requirements included in statutes or regulations

-Non-primary care providers: The first and last name of the referring physician and the referral number given by the referring physician if applicable to the service

-On-call physicians: Physicians who are on call for a primary care physician (PCP) do not require a referral. On-call physicians who treat a patient linked to a PCP in their group practice must include comments documenting the circumstances of the coverage in the Remarks section located on the CMS-1500 claim form.

General billing Requirements:

Patient ID number: Enter the corresponding identification (ID) number as noted below:

-Member ID number: The nine-character (in most cases, eight digits followed by a letter) The ID number can be found on the patient's VCHCP ID card.

-National Provider Identifier: A unique ten-digit numeric identifier assigned to healthcare providers and organizations defined as covered entities under HIPAA. Beginning May 17, 2008, VCHCP moved into compliance with the NPI mandate and began to enforce use of the NPI.

Specific Billing Requirements:

Ambulance (air and land) claims: Trip reports are not needed for 911 referral claims but are required for non-emergent medical transportation or other medical services not resulting in transport.

Anesthesia claims: Use anesthesia CPT codes to bill for anesthesia procedure services and include a modifier to identify the patient's physical status. Bill the base unit value as the service unit for each procedure. Add time units (15 minutes = 1 unit of service) to claims to indicate anesthesia start and stop times.

Assistant surgeon: Include assistant surgeon's name as rendering provider on the CMS-1500 form. Use -80, -81 or -82 modifier after the surgical CPT code.

Bilateral procedures: When a surgical procedure is performed on more than one side of the body at the same operative session, payment of the secondary procedure (indicate with modifier -50) will be reduced.

Coordination of benefits (COB): When VCHCP is the secondary payer, the provider must submit the claim and a copy of the Explanation of Medical Benefits/Explanation of Benefits (EOMB/EOB) from the primary carrier to VCHCP for payment consideration.

The COB provision ensures that:

• Benefits paid by multiple group health plans do not exceed 100 percent of eligible expenses, and
• There is no duplication of benefits, and
• There is a consistent order of payment when a member has multiple group health plans.

Increased procedural services: When billing modifier 22 (increased procedural services) include the surgical report that documents the justification of billing this modifier, highlighting the pertinent section of the records.

Injectable medications: When billing for injectable medications, list appropriate HCPCS code identifying medication with appropriate units, and method of administration.

Multiple diagnoses: Indicate on the professional 1500 CMS claim form the specific diagnosis for each procedure code billed.

Multiple procedures: When applicable to the surgical service use modifier -51 to indicate that a surgical service is secondary or latter in sequence to the primary surgical service to allow reduction in payment. Note: Add-on codes are exempt from payment reduction.

Multiple visits: If billing for two visits for the same patient on the same day, include chart or hospital notes.

Unlisted (or miscellaneous CPT code) billing: Identify the unlisted procedure by including a description of the service on the claim form. Submit an attachment with the claim including the following information:

• An explanation that indicates what the service consisted of
• Highlight the portion of the medical record pertaining to the unlisted service being billed.
• Provide a comparative CPT code to the unlisted service and include an explanation why it is a comparable service.

VCHCP is required to provide an acknowledgement of claims receipt within two (2) business days for electronically submitted claims.

For electronic claims submitted via clearinghouse: The claims clearinghouse utilized by VCHCP provides the acknowledgement directly to the provider of service within two business days when claim submissions are successfully transmitted via the claims clearinghouse website.

For claims received via other electronic means, VCHCP will provide electronic acknowledgement in the same manner within two business days.

Paper claim submission: For claim submissions received via paper, VCHCP will provide an acknowledgement via paper of claim receipt within fifteen (15) business days of receipt of the paper claim.

Date of Receipt

Date of receipt is the business day when a claim is first delivered, electronically or physically to VCHCP's designated address.

Provider Claim Status Inquiry Requests

Providers may request status of a claim or group of claims by the following methods:

• Contact the VCHCP Claims Processing Unit via telephone at (805) 981-5030.
• Submit a request via facsimile to the VCHCP Claims Processing Unit Fax line at (805) 981-5031.
• Mail a request to the claims processing unit as indicated below.

All provider inquiries and supporting information should be mailed to:

VCHCP
Claims Processing Unit
2220 E. Gonzales Road
Suite 210B
Oxnard, CA 93036

The inquiry for claim status should include the following information:

• Patient name
• VCHCP policy number
• Patient account number
• Date of service
• Billed services
• Billed charges
• Provider's contact information
• Provider's return reply information
• Company/provider name
• Contact name and working title of requestor

VCHCP will reimburse each complete provider claim, or potion thereof, according to the agreed upon contract rate no later than 45 business days after receipt of the claim unless the claim is contested or denied. VCHCP reserves the right to adjudicate claims using reasonable payment policies and non-standard coding methodologies that are consistent with standards accepted by nationally recognized medical organizations, federal regulatory bodies and major credentialing. In general, Medicare guidelines are used by VCHCP for claims processing.

Please refer to the above sections titled 'What is a complete claim?', 'Are there instructions for general billing requirements?', 'General Billing Requirements' and 'Specific Billing Requirements' for additional information on billing instructions.

The late payment on a complete claim for emergency services that is neither contested nor denied will automatically include the greater of:

     -      for each 12-month period or portion thereof on a non-prorated basis; or,

     -     Interest at the rate of 15 percent per year for the period of time that the payment is late

The late payment on a complete claim for all other services that is neither contested nor denied will automatically include interest at the rate of 15 percent per year for the period of time that the payment is late.

If VCHCP does not automatically include the interest fee with a late-paid complete claim, an additional will be sent to the provider of service.

If VCHCP fails to notify the provider of service in writing of a denied or contested claim, or portion thereof, and ultimately pays the claim in whole or part, computation of the interest will begin on the first calendar day after the applicable time period for denying or contesting claims has expired.

Overpayment of Claims: If VCHCP determines that an overpayment has occurred, VCHCP will notify the provider of service in writing within 365 days of the date of payment on the overpaid claim through a separate notice that includes the following information:

-Member name
-Claim ID number
-Date of service
-A clear explanation of why VCHCP believes the claim was overpaid
-The amount of overpayment, including interest and penalties

The provider of service has 30 working days to submit a written dispute to VCHCP if the provider does not believe an overpayment has occurred. At this point, VCHCP will treat the claims overpayment issue as a provider dispute.

If the provider does not dispute the overpayment, the provider of service must reimburse VCHCP within 30 working days from the receipt of VCHCP's notice.

VCHCP may recoup uncontested overpayments by offsetting overpayments from payments for a provider's current claims if:

-The provider's Provider Services Agreement (PSA) with VCHCP authorizes it to offset overpayments from payments for current claims for services.

-A written notification is sent to the provider of service if an overpayment is recouped through offsets to claim payments via an agreement entered into by VCHCP and the provider. The notification will identify the specific overpayment and the claim ID number.

(Provider Dispute Resolution Processes)

Definition of a Provider Dispute: A provider dispute is a written notice from the contracting provider to VCHCP that:

-Challenges, appeals or requests reconsideration of a claim (including a bundled group of similar claims) that has been denied, adjusted or contested
-Challenges a request for reimbursement for an overpayment of a claim
-Seeks resolution of a billing determination or other contractual dispute

(Provider Dispute Timeframe)

VCHCP will accept disputes from contracting providers if they are submitted within 365 days of receipt of VCHCP’s decision (for example, denial or adjustment in writing such as an EOB date) except as described below. If the provider does not receive a decision from VCHCP, the dispute must be submitted within 365 days after the time for contesting or denying the claim has expired.

If the provider’s Provider Services Agreement (PSA) provides for a dispute-filing deadline that is greater than 365 calendar days, this longer timeframe will continue to apply unless and until the contract is amended.

(Submission of Provider Disputes)

When submitting a provider dispute, a provider may use a Provider Dispute Resolution Request Form. If the dispute is for multiple, substantially similar claims, a Provider Dispute Resolution Request Spreadsheet must be submitted with the Provider Dispute Resolution Request Form.

The provider dispute must include the provider’s name, ID number, contact information including telephone number, and the same number, and the same number, and the same number assigned to the original claim. Additional information is required if:

-The dispute is regarding claim or a request for reimbursement of an overpayment of a claim, the dispute must include a clear identification of the disputed item, the date of service, and a clear explanation as to why the provider believes the payment amount, request for additional information, request for reimbursement of an overpayment, or other action is incorrect
-The dispute is not about a claim, a clear explanation of the issue and the basis of the provider’s position therein.

A provider dispute that is submitted on behalf of a member will be processed through the member appeal process provided the member has authorized the provider to appeal on behalf of the member. When a provider submits a dispute on behalf of a member, the provider is assisting the member with his or her member appeal.

If the provider dispute involves a member, the dispute must include the member’s name, ID number, and a clear explanation of the disputed item, including the date of service, and the provider’s position therein.

All provider disputes and supporting information must be submitted to:

Address:

VCHCP Appeals Unit
2220 E. Gonzales Road
Suite 210B
Oxnard, CA 93036

If the provider dispute does not include the required submission elements as outlined above, the dispute will be returned to the provider along with a written statement requesting the missing information to resolve the dispute. The provider must resubmit the dispute along with the missing information within 30 working days from the receipt of the request for additional information.

VCHCP will not request that providers resubmit claim information or supporting documentation that was previously submitted to VCHCP as part of the claims adjudication process unless VCHCP returned the information to the provider.

VCHCP will not discriminate or retaliate against a provider due to a provider’s use of the provider dispute process.

Acknowledgement of Provider Disputes:

VCHCP will acknowledge receipt of each provider dispute, regardless of whether or not the dispute is complete, within 15 business days of receipt for a paper submission or 2 business days for an electronic (fax/email) submission.

Resolution Timeframe

VCHCP will resolve each provider dispute within 45 business days following receipt of the dispute, and will provide the provider with a written determination stating the reasons for determination. If VCHCP cannot resolve the dispute within the 45 business day time frame it will request additional information from the provider. The provider has 30 working days to respond. If it does not respond VCHCP will close the dispute.

Past Due Payments:

If the provider dispute involves a claim and is determined to be in favor of the provider, VCHCP will pay any outstanding money due, including any required interest or penalties, within five business days of the decision. Accrual of interest and penalties will commence on the day following the date in which the claim should have been processed.