CarePlus Provider Claims

Claim Payments

EFT and ERA Enrollment Process for Claim Payments and Remittance Advices

To enroll in electronic funds transfer (EFT) and electronic remittance advice (ERA), simply complete the EFT/ERA form and fax it to the provider operations department at 1-855-659-7966. You also may mail your completed form to:

CarePlus Health Plans
Attn: Provider Operations department
Hector Cuy, Manager, Network Administration
11430 NW 20th St., Suite 300
Miami, FL 33172

Additional Information: CarePlus works with Change Healthcare to send ERAs to providers. Please work with your system vendor or billing service to enroll for ERA for CarePlus Health Plans. To enroll directly with Change Healthcare:

  • Go to http://www.emdeon.com/enrollment/ .
  • Click on “Setup Forms,” which is found on the left side of the page.
  • Scroll down to “ERAPSF.”
  • Complete and submit the form to Change Healthcare via the fax number or email address listed on the form.
  • Note: The CarePlus Health Plans payer ID for Change Healthcare is 65031.

If at any time you have questions about the form, please call our provider operations department at 1-866-220-5448 (choose prompt 6, then 4), Monday through Friday from 8 a.m. to 4 p.m.

Claims Submissions

Claims submitted for processing should be in a HIPAA-compliant 837 file format and filed electronically with Availity at www.availity.com (link opens in new window)  using the CarePlus payer ID 95092 (specific to Availity), or with Change Healthcare at www.ChangeHealthcare.com (link opens in new window)  using the CarePlus payer ID 65031 (specific to Change Healthcare). Providers should work with their practice management system, system vendor or billing service to ensure CarePlus Health Plans is enabled for electronic claim submission. If unable to submit electronically, health care providers can submit their professional claims on a properly completed CMS 1500 form within the time frame specified in their contracts. Providers may use the revised 1500 claim form (version 02/12) effective Jan. 6, 2014. This approved updated 1500 claim form accommodates reporting needs for ICD-10 and aligns with requirements in the Accredited Standards Committee X12 (ASC X12) Health Care Claim: Professional (837P) Version 5010 Technical Report Type 3.

If unable to submit facility claims electronically, providers may submit them on a properly completed UB-04/CMS 1450 form within the time frame specified in their contracts. If all electronic data interchange (EDI) methods have failed, and the provider has already contacted his or her CarePlus Provider Services executive for assistance, then the paper claim submission and claim-related correspondence should be mailed to the following address:

CarePlus Health Plans
Attn: Claims department
P.O. Box 14697
Lexington, KY 40512-4697

Not submitting a clean, properly completed claim will delay processing. Health care providers may refer to the National Uniform Claim Committee for more information.

CarePlus’ contracted provider filing limitation is 180 days from the date of service or the through date of service listed on the claim form, whichever is the later date. The noncontracted provider filing limitation is 12 months from the date of service or the through date of service listed on the claim form, whichever is the later date.

Electronic Data Interchange (EDI) Corrections and Reversals

The 837 TR3 (Technical Report Type 3) defines what values submitters must use to signal to payers that the inbound 837 contains a reversal or correction to a claim that was previously submitted for processing. For both professional and institutional 837 claims, 2300 CLM05-3 (Claim Frequency Code) must contain a value from the National UB Data Element Specification Type List, Type of Bill, Position 3. Values supported for corrections and reversals are:

  • 5 = "Late charges only" claim
  • 7 = Replacement of prior claim
  • 8 = Void/cancel of prior claim
  • Q = Reopening for institutional claim only

The following coding must be used:

Loop 2300
Segment CLM05-3 = 7
Segment REF01 = F8
Segment REF02 = the 13-digit original claim number - no dashes or spaces

If submitting via paper:

Professional corrected claims or voided claims that have a “7” or “8” in Box 22 include the original claim number in the ORIGINAL REF NO field. When there is a 7 code populated in Box 22, the new claim will follow the replacement of prior claim process. When there is an 8 code populated in Box 22, the new claim will follow the void/cancellation of the prior claim process.

Institutional corrected claims or voided claims that have a “7” or “8” in Box 4 (Type of Bill) include the original claim number in Box 80 REMARKS. When the applicable frequency code is populated, the new claim will follow the applicable correction or void process. The number 7 represents replacement of prior claim; 8 represents a void or cancellation of a prior claim.

Effective Oct. 5, 2015 (for institutional claims only), when the need for a correction is discovered beyond the claim’s timely filing limit of one year, an institutional provider must utilize the reopening process using the new bill type frequency, submitting with a “Q” in Box 4 (Type of Bill) to identify it as a reopening and a series of condition codes that can be utilized to identify the type of reopening being requested. Reopenings that require “good cause” to be documented must have a remark/note from the provider.*

For more information, see CMS MLN Matters Number: MM8581 “Automation of the Request for Reopening Claims Process.”

*Institutional providers may request a reopening for any reason within one year from the date of the original determination or redetermination. Providers also may request a reopening for “good cause” within four years from the date of the original determination or redetermination. Good cause exists when:

  • There is new and material evidence that was not available or known at the time of the determination or decision and may result in a different conclusion; or
  • The evidence that was considered in making the determination or decision clearly shows on its face that an obvious error was made at the time of the determination or decision.

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