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UPREHS Billing

Non-Medicare Members

  • Claims Submission: Timely filing limit for claims is one year from the date of service. Claims Electronic filing is preferred and will result in faster payments. Providers may submit claims electronically to the local Anthem BlueCross BlueShield unit. All claims, whether the provider is participating in the network or not, will be submitted to the local Anthem BlueCross BlueShield unit.
  • Claims Payments: UPREHS’ payment of claims is determined when the claim is presented, not when eligibility is verified. Only services that are a benefit of the member’s plan will be paid. We employ industry standardized edits which may reduce or deny specific charges based on the information submitted on the claim. Providers not in the Anthem or BlueCross network will be paid based on the Plan Allowable Amount, as determined by Anthem. (link to the attachment).
  • Claim payment reductions: Claims to in-network providers will be based on the network agreement and plan benefits. Claim payments to out-of-network providers will be reduced to 40% of the plan allowable amount. Payments will be reduced or denied for both in-patient and out-patient services that require precertification as appropriate.
  • Appeal of Claims Payment or Denials: The member or member representative may appeal, in writing within 180 days following the initial notice of payment or denial, if they believe a claim was incorrectly denied or payment was incorrectly reduced.
  • Providers may appeal in writing for discounts, limits, or edits that they believe to be incorrect. Appeals must be presented to the local Anthem BlueCross BlueShield unit.
  • UPREHS Member Benefit Contract Disclosure with Anthem - Effective 9/01/2013

Billing for Medicare Members

  • Claims Submission: Claims for Medicare secondary benefits under UPREHS must be filed with UPREHS within one-year of the time the claim was first processed by any Medicare claims processor. Electronic filing is required and will result in faster payments. Providers may submit claims with Payer ID# 87042. Paper claims, black and white claims, and faxes, will not be accepted.
  • Claims Payments: UPREHS’ payment of claims is determined when the claim is presented, not when eligibility is verified. Only services that are a benefit of the member’s plan will be paid. Claims to in-network providers will be based on the network agreement at 100% of the contracted rate for HCPP or 100% of the Medicare co-insurance and deductible amounts. Claim payments for out-of-network providers will be reduced to 40% of the Medicare co-insurance and deductible amounts. If Medicare denies coverage for a service UPREHS will also deny coverage.
  • Appeal of Claims Payment or Denials: The member, member representative or a provider may appeal, if they believe a claim was incorrectly denied or payment was incorrectly reduced. Please see the Medicare HCPP & Medicare Secondary Benefit Guide, Section 10, Coverage Decisions and Appeals.
  • If network payment discounts were applied and you believe the payment is incorrect, please appeal claims to First Health Provider Services at (800) 937-6824.
 
 

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