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.
Important Updates
- 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. |
Claims Resources
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:
VNS Health
Health Plans
P.O. Box 4498
Scranton, PA 18505
Or call us at:
1-866-783-0222
(TTY: 711)
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.
It’s easy to check on the status of a claim you’ve submitted by signing in to the Provider Portal.
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
Participating providers can dispute a claim or utilization review decision using the Online Form available on vnshealthplans.org. Disputes need to be submitted within the timeframe stated in the provider’s contract.
Below are general claims dispute timelines for reference. However, providers must submit disputes within the timeframe within their contract in order for the dispute to be considered.
- LHCSAs/Fls – Sixty (60) days to dispute a claim from VNS Health issued Remittance notice or Explanation of Benefits
- SNFs – Sixty (60) days to dispute a claim from VNS Health issued Remittance notice or Explanation of Benefits
- Meals on Wheels – Ninety (90) days to dispute a claim from VNS Health issued Remittance notice or Explanation of Benefits
- Ancillary Providers – Six (6) months to dispute a claim from VNS Health issued Remittance notice or Explanation of Benefits. This also includes disputes for Cost Outlier underpayment. It is necessary to submit the relevant Medical Records within this timeframe. Failure to do so will result in a denial of the claim as untimely.
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:
VNS Health
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.
To ensure your corrected claims are processed and paid correctly, please follow these essential steps:
1. Clearly Identify the Original Claim:
- UB-04 Forms:
- Mark “Frequency Code 7” to indicate a replacement claim.
- Use type of bill “XX7” in box 4 (electronic or paper).
- CMS 1500 Forms:
- Enter “7” in Resubmission Code box (Box 22).
- Provide the original claim number in the Original Reference Number field (also within Box 22).
2. Reference the Correct Claim Number:
- Always include the exact claim number you’re correcting.
- If correcting an adjusted claim, use the adjusted claim number (e.g., XXXXXXXXXX01), not the original one.
- Failure to provide the correct claim number will lead to denial.
3. Adhere to Timely Filing Requirements:
- Submit corrected claims within the specified timeframe to avoid denials based on lateness.
4. Include Condition Codes for Medicare Services:
- Corrected claims for Medicare services require specific condition codes based on CES edits.
- Omitting these codes can result in denials.
Key Points to Remember:
- Clearly identify corrected claims using appropriate codes and fields.
- Always reference the correct claim number being corrected.
- Follow timely filing requirements.
- Include condition codes for Medicare services.
- Adhering to these guidelines will significantly increase the likelihood of your corrected claims being processed and paid accurately.
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.
Varis to Conduct Post-payment Inpatient DRG Review
Beginning 5/1/2023, Varis, an organization specializing in strategic analysis of health care claims, will conduct post-paid reviews of inpatient claims to validate the claims are in accordance with guidelines.
Varis will do two types of reviews:
- Post Payment Clinical Validation
Varis will conduct Clinical Validation reviews to confirm the diagnoses documented in the medical record are sustained by clinical criteria generally accepted by the medical community.
- VARIS will send letters notifying providers of the claims selected for review and requesting copies of the relevant portions of the medical record.
- Providers should send the requested portions of the records electronically, if possible. VARIS will apply CMS requirements and guidance and VNS Health Health Plans’ policy.
- A licensed Registered Nurse or MD will conduct the reviews, applying CMS requirements and guidance and VNS Health Health Plans’ policy. Final determinations are made by a licensed Physician.
- If the clinical criteria are not met:
- VARIS will provide the medical records to an Independent Peer Review Organization.
- A licensed board certified physician will review the records to determine whether the clinical documentation in the record is sufficient to support the condition. If the condition is not supported, the entire claim payment amount will be considered an overpayment.
- If a provider fails to comply with a request for medical records, VARIS will send a reminder notice. If the provider fails to provide the requested medical records after receiving the reminder, the entire claim payment amount will be considered an overpayment.
- In the event of an overpayment finding:
- VARIS will notify the provider by letter and request the provider acknowledge the overpayment or provide additional or clarifying information within 30 calendar days.
- If an acknowledgment or additional information is not received after 20 days, VARIS will send a reminder letter.
- If VARIS does not receive an acknowledgment or additional information within the 30- day timeframe, VARIS will send a final letter informing the provider that VNS Health will be notified to conduct the adjustment or collection process for that specific overpayment.
- If a case is being appealed, the Independent Peer Review Organization will review the case by a secondary licensed board-certified physician.
- Post-payment Readmission DRG Review
Varis will conduct DRG readmission reviews for acute care facility inpatient claims that are paid based on Medicare Severity Diagnosis Related Group (MS-DRG) payment methodology.
- VARIS will send letters notifying providers of the records selected for review and requesting copies of the relevant portions of the medical record be sent within 30 days.
- Providers should send the requested portions of the records electronically, if possible. VARIS will apply CMS requirements and guidance and VNS Health Health Plans’ policy.
- A licensed Registered Nurse or MD will conduct the reviews, applying CMS requirements and guidance and VNS Health Health Plans’ policy. Final determinations are made by a licensed Physician.
- If a provider fails to comply with a request for medical records, VARIS will send a reminder notice. If the provider fails to provide the requested medical records after receiving the reminder, the entire claim payment amount will be considered an overpayment.
- In the event of an overpayment finding:
- VARIS will notify the provider by letter and request the provider acknowledge the overpayment or provide additional or clarifying information within 30 calendar days.
- If an acknowledgment or additional information is not received after 20 days, VARIS will send a reminder letter.
- If VARIS does not receive an acknowledgment or additional information within the 30- day timeframe, VARIS will send a final letter informing the provider that VNS Health will be notified to conduct the adjustment or collection process for that specific overpayment.
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.