Claims and Payment Information and Resources
Your Claims and Remittances
We understand that easy filing and timely payment of claims are a high priority for our providers. Although you may submit paper claims by mail, there are many benefits to submitting claims electronically, such as improved accuracy, reliability, convenience, and expedited payments.
Claims must be received within 90 days of the date of services (or the time frame stipulated in your contract). If we are not the member’s primary insurance, please submit the claim within 90 days of the date on the Explanation of Payment from the primary carrier.
- All Claim Disputes must be submitted through our Provider Claim Dispute Form. Disputes that are not sent through our Provider Claim Dispute Form will not be addressed. If you are unsure whether to submit a Claim Dispute or Claim Appeal, please click “Should I submit a Claim Dispute or Claim Appeal?” below.
- Availity is the preferred EDI and Portal vendor for all health plan transactions. Please see “How to submit an electronic claim” below.
|Electronic Payment for Providers|
|It’s easy to further expedite your claims payments by signing up for electronic funds transfer (EFT) payments that are direct deposited into your bank account. You don’t have to wait for our checks to arrive in the mail or manually sort, reconcile, and deposit checks. |
You will need to complete both of the following two steps to begin receiving EFT payments and remittances:
1. To set up EFT payments, fill out the EFT Request Form.
2. To receive electronic remittance advice files, enroll with Availity directly.
For more information, please contact a Provider Services representative at 1-866-783-0222, or email us.
Consult the additional resources below for answers to your questions about claim forms, remittances, billing codes, and the transition from ICD-9 codes to ICD-10 codes.
If you have any questions or require further assistance, please visit our Contact Us page, or call Provider Services at 1-866-783-0222, Monday–Friday, 8 am–5 pm.
Availity is the preferred EDI and Portal vendor for all health plan transactions. Availity is committed to working with providers and their vendors to ensure there is no disruption in the transmission of your transactions. For this reason, we’d like to share important information regarding your electronic claim submission, eligibility status verification, electronic remittance advice, and claim status verification. The existing Payer IDs — 77073 and VNS Health — are not changing and will be used moving forward.
If you wish to submit directly, you can connect directly to the Availity Gateway at no cost for all VNS Health Health Plans 837, 835, and 27X transactions.
Please visit https://apps.availity.com/web/welcome/#/edi and availity.com/vns to help set up your business or vendor for submitting EDI transactions through Availity.
Availity’s Provider Engagement Portal is accessible for the following transactions as well: eligibility and benefits inquiry, claim submission, claim status inquiry, and electronic remittance advice. Please ensure you are registered with Availity for this access (https://www.availity.com/provider-portal-registration).
If you have additional questions or need assistance, please contact Availity Client Services at 1-800-Availity (1-800-282-4548), Monday–Friday, 8 am–8 pm (ET).
For hard copy (paper) submissions:
P.O. Box 4498
Scranton, PA 18505
Or call us at:
Monday–Friday, 8 am–5 pm
Covered Part D vaccine claims should be mailed to:
MedImpact Healthcare Systems
P.O. Box 509108
San Diego, CA 92150-9108
Click on “Required data elements for claim forms” below for sample forms and a list of required data elements, MLTC provider billing instructions for MLTC and nursing home providers, and provider codes for adult day care, chore services, and home-delivered meals providers.
To receive electronic remittance advice files, you’ll need to enroll directly with our EDI clearinghouse, Availity.
Please visit availity.com/vns for a quick reference guide to exchanging EDI transactions through Availity.
For a line-by-line guide to reading remittance forms, please view our Provider Remittance Fact Sheet.
When to use the Provider Claim Dispute Form:
- Coding denials
- Underpaid/overpaid claims
- Invalid procedure code/revenue code/diagnosis code
- Incorrect modifier
- Denied for authorization and provider has authorization letter
You can also consult Section 9 of our provider manual to review the list of requirements needed for filing a dispute.
When to submit a Claim Appeal:
If your claim is denied, and you wish to challenge the decision, you can use the grievances and appeals process. This will lead to an internal clinical or administrative review of the denial.
Examples of appealable denials include:
- Services not authorized
- Not medically necessary
- Noncovered service
- Noncovered benefit
- Benefit exhausted
- Charges previously considered
Please click here for complete instructions for submitting a Provider Claim Dispute.
- When submitting a disputed claim, you must include an Excel attachment. Download this template, and use it to enter the information listed in each column. We’ll need it in order to process your payment dispute. (Note that if you don’t see the template right away, check your browser’s download status bar or the download file on your computer.)
- Attach the file in the field labeled “File upload” when you submit your dispute using the Claim Dispute Form.
- Look for an email confirmation of your submission.
You can also consult Section 9 of our provider manual to review the list of requirements needed to file a dispute.
If you want to file an appeal, the request must be submitted in writing, via fax or mail.
Please fax your request to 1-866-791-2213.
Or mail it to:
Health Plans – Grievances & Appeals
P.O. Box 445
Elmsford, NY 10523
Consult Section 9 of our provider manual to review the list of requirements and time frames needed for filing an appeal.
Claim Appeals: Notification of a decision will be made within 60 calendar days of receiving the appeal. If you are an out-of-network provider filing a claim appeal, a decision may take up to 120 days if a completed Waiver of Liability form is needed. No extension may be taken on payment appeals, and payment appeals cannot be processed as “fast” appeals.
The CMS-1500 claim form (sample) and UB-04 claim form (sample) can be used to bill fee-for-service encounters. The UB-04 claim form should be used by facilities and by facilities billing on behalf of employed providers.
Please be sure your claim has these required data elements before submitting your form. This information is needed for claims to be processed correctly.
You can find instructions for submitting your claim by clicking on “How to submit claims” above.
In-network providers should follow these billing procedures when submitting claims to a VNS Health health plan.
These are the most frequently asked questions about the transition from ICD-9 codes to ICD-10 codes and how the transition affects our in-network providers.
If you are a physician who ordinarily provides primary or specialty care services to a patient who is now in hospice, you should bill us directly. You do not need to bill both CMS and VNS Health Medicare, unless you are specifically a hospice provider or facility. For more-detailed information, visit Hospice Benefit FAQs.
Visit Billing Instructions for Nursing Home Providers for information about billing and claims procedures.