Claim Processing and Medical Coverage Policies and Procedures

As a Participating Provider, you agree to adhere to CarePlus' claims processing and medical coverage policies and procedures when submitting claims.

  • Claims Processing Commitment: CarePlus is committed to processing and adjudicating clean and complete claims in accordance with our established claims processing and medical coverage policies.
  • Policy Overview: Our claims processing and medical coverage policies include various claim and code edits, as well as automated system applications that:
    • Identify, analyze, and compare the amounts claimed for payment against the corresponding diagnosis and procedure codes.
    • Examine the relationships among the billing codes utilized to represent the covered services provided to CarePlus-covered patients.
  • Claims Handling Procedures: CarePlus' policies and procedures allow for the following actions:
    • Denial, in whole or in part, of a claim.
    • A request for the submission of medical records related to a claim prior to payment. Claims may be denied, in whole or in part, if the requested medical records are not submitted within the specified timeframe.
  • Payment Adjustments: It is important to note that a reduction or denial of payment for a claim does not indicate or imply that the healthcare item or service provided is a non-covered service.
  • Billing Restrictions: Providers are not permitted to bill a CarePlus-covered patient for any amount associated with a claim that has been denied or adjusted in payment.

For further information, please refer to the CarePlus Provider Manual  for detailed guidelines and resources.

View our claims processing and medical coverage policies and procedures

View our code editing and payment process

EFT and ERA for Claim Payments and Remittance Advices

To enroll in electronic funds transfer (EFT) and electronic remittance advice (ERA), you must register with Availity Essentials™.

  • Enroll on Availity Essentials

    To enroll on Availity:

    • Select My Providers | Enrollments Center in the top navigation bar
    • Select Transaction Enrollment under Multi-Payer Enrollments
    • On the Transaction Enrollment - Enrollment Status page, select Enroll and then select Enroll a provider. The Transaction Enrollment - Enroll page will display.
    • Note: The CarePlus Health Plans payer ID for Availity is 95092. 
    • If you have questions about the form, please call Availity Client Services at 800-282-4548, Monday – Friday, 8 a.m. to 8 p.m., Eastern time

Claim Submissions 

Please submit medical claims for processing in a HIPAA-compliant 837 file format and file them electronically with Availity Essentials using CarePlus payer ID 95092 (specific to Availity).

Please submit dental claims for processing in a HIPAA-compliant 837 file format and file them electronically with Availity Essentials using the Humana Dental claims payer ID 73288.

Access information about the submission of claims for dental services inextricably linked to one or more medical services

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, providers can submit 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). 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 in 837I file format, providers can 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 fail, and you’ve already contacted your provider services executive for assistance, mail the paper claim submission and claim-related correspondence to the following address: 

Medical claims

CarePlus Health Plans
Attn: Claims Department
P.O. Box 14601
Lexington, KY 40512-4601

Dental claims

Humana Dental Claims Office
P.O. Box 14611
Lexington, KY 40512-4611

Not submitting a clean, properly completed claim will delay processing. 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 non-contracted 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. 

Participating provider requests for claims reconsiderations 

Participating providers can submit a request reconsideration of a claim denial or payment amount. 

Requests for Review of Denied Claims

To request a review of service or claim payment denials by the Plan, providers can call CarePlus provider services at 866-220-5448 (the number that is listed on the back of the Member’s ID card) or mail a written request to the CarePlus Claims address at P.O. Box 14601, Lexington, KY 40512-4601.

Provider Claim Reconsideration/Dispute Process

If a provider disagrees with CarePlus’ initial review determination (conveyed via electronic or paper remittance advice) and would like to dispute it, the provider can do so by writing to CarePlus at:

CarePlus Correspondence
P.O. Box 14601
Lexington, KY 40512-4601

When submitting a written request for a dispute, providers must include the following information:

  • Provider name
  • Provider NPI and Tax ID
  • Member name and identification number
  • Date of service
  • Relationship of the subscriber to the patient
  • Claim number
  • Charge amount
  • Payment amount
  • Proposed correct payment amount
  • Difference between the amount paid and the proposed correct payment amount
  • Brief description of the basis for the contestation request
  • Relevant supporting documentation (e.g., medical records, copy of invoice, referral form) 

NOTE: Claims disputes must be received by CarePlus within 18 months of the date the claim was paid—unless state or federal law or the agreement require another time period—or the claim will not be reopened.

If the provider is unsatisfied with the outcome of the review of their dispute, they can submit a second dispute following the same process outlined above.

Important Note for Delegated Providers

Claim issues or provider disputes must be submitted directly to the delegated entity and reviewed in accordance with the delegated entity’s claim resolution process. For additional details, please refer to the delegated entity you are affiliated with and/or your participating provider agreement with said entity.

Electronic Data Interchange (EDI) Corrections and Reversals 

The 837 TR3 (Technical Report Type 3) defines the 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, the 2300 CLM05-3 (claim frequency code) must contain a value from the National UB Data Element Specification Type List, Type of Bill and Position 3. Values supported for corrections and reversals are: 

  • 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 should include the original claim number in the ORIGINAL REF NO field. When a 7 code populates in Box 22, the new claim will follow the replacement-of-prior-claim process. When an 8 code populates 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) should 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; the number 8 represents a voiding or cancellation of a prior claim. 

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. The provider also should include a series of condition codes that can be used to identify the type of reopening being requested. Reopenings for “good cause” must have a remark/note from the provider.* 

*Institutional providers can 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 that may result in a different conclusion; or 
  • The evidence that was considered in making the determination or decision clearly shows that an obvious error was made at the time of the determination or decision.

H1019_CPHPProvider_C _6080FL0822

Last Updated:

01/01/2026