Claims and Billing

Submit claims through electronic data interchange (EDI) for faster, more efficient claims processing and payment. AmeriHealth Caritas New Hampshire EDI payer ID number is 87716.

Electronic claims may be submitted via:

Availity

• Providers or clearinghouses not currently using Availity to submit claims, must register at: https://www.availity.com/intelligent-gateway/.
• Providers who are currently registered with Availity for another payer, or using another clearinghouse, must request to have electronic claims for AmeriHealth Caritas New Hampshire routed to Availity.
• For registration process assistance, submit the Provider Inquiry form at the bottom of the Availity webpage or contact Availity Client Services at 1-800-AVAILITY (1-800-282-4548). Assistance is available Monday through Friday from 8 a.m. to 8 p.m. ET.

Optum/Change Healthcare

• Providers who have a software vendor or use another clearinghouse to submit claims to Optum/Change Healthcare will need to consult with their vendor/clearinghouse to see if there have been changes in their process for claims submission.
• For questions contact Optum/Change Healthcare’s call center at: 1-800-527-8133, Monday through Friday from 8 a.m. to 8 p.m. CT.

Providers may submit manual/direct entry claims (at no cost) via:

Optum/Change Healthcare ConnectCenter™

Access the portal via the Claims submission link in the NaviNet provider portal or via https://physician.connectcenter.changehealthcare.com/#/site/home?vendor=214629 to complete your provider registration.

Note: This URL is specific to new provider registration only. For detailed instructions on the registration process, see the Provider Sign-up and User Management guide in the Claim Resource section at the bottom of this page.

Follow the instructions on the login page to reset your password and to set up the required multi-factor authentication.

For more information on available functionality, please review the release notes in the Product News section after signing into the ConnectCenter portal.

Optum/Change Healthcare provides other helpful user guides to assist providers with navigating the ConnectCenter portal. These guides are also available in the Claim Resource section at the bottom of this page.

PCH Global

To enroll for claims submission through PCH Global please go to: https://pchhealth.global.

1. Click the Sign-Up link in the upper right-hand corner.
2. Complete the registration process and log into your account. You will be asked how you heard about PCH Global; select Payer, then AmeriHealth. Access your profile by clicking on Manage User and then My Profile. You will need to complete all the profile information. When you go to the Subscription Details screen, select the More option on the right-hand side to see how to enter the promo code Exela-EDI.
3. When you are ready to submit claims, use the following information to search for our payer information:
   • Payer name: AmeriHealth Caritas
   • P.O. Box: 7386

For a detailed walk-through of the registration process, refer to the PCH Global Registration manual (PDF), found on the PCH Global website in the Resource Menu.

Send paper claims to:

AmeriHealth Caritas New Hampshire
Claims Processing Department
P.O. Box 7387
London, KY 40742-7387

AmeriHealth Caritas New Hampshire is accepting ANSI 5010 ASC X12 275 claim attachment transactions (unsolicited). Please contact your Practice Management System Vendor or EDI clearinghouse to inform them that you wish to initiate electronic 275 claim attachment transaction submissions for payer ID: 87716 via:

Availity

There are two ways 275 claim attachments can be submitted:

• Batch — You may either connect to Availity directly or submit via your EDI clearing house.
• Portal — Individual providers may also register at https://www.availity.com/Essentials-Portal-Registration to submit attachments.

After logging in, providers registered with Availity may access the Attachments - Training Demo for detailed instructions on the submission process via: Training Link or refer to the Availity Claims Attachment Quick Reference guide located under Claims Resources at the bottom of this page.

Optum/Change Healthcare

• There are two ways that 275 attachments can be submitted:
  • Batch — You may either connect to Optum/Change Healthcare directly or submit via your EDI clearing house.
  • API via JSON — You may submit an attachment for a single claim.

View the Optum Change Healthcare 275 claims attachment transaction video for detailed instructions on this process.

General guidelines

• A maximum of 10 attachments are allowed per submission. Each attachment cannot exceed 10 megabytes (MB) and total file size cannot exceed 100MB.
• The acceptable supported formats are pdf, tif, tiff, jpeg, jpg, png, docx, rtf, doc, and txt.
• The 275 attachments must be submitted prior to the 837. After successfully submitting a 275 attachment, an Attachment Control Number will generate. The Attachment Control Number must be submitted in the 837 transactions as follows:
• CMS 1500
  • Field Number 19
  • Loop 2300
  • PWK segment
• UB-04
  • Field Number 80
  • Loop 2300
  • o   PWK01 segment

In addition to the attachment control number, the following 275 claim attachment transaction report codes must be used when submitting an attachment. Enter the applicable code in field number 19 of the CMS 1500 or field number 80 of the UB04, as documented in the claims filing instructions (PDF).

To inquire about claim status, sign in to NaviNet and select Claims Status Summary under Administrative Reports. Provider Claim Services can also check the status of up to 5 claims via phone at 1‑888‑599‑1479.

Requests for reconsideration may be submitted through the NaviNet Electronic Claim Inquiry feature. For detailed information on electronic claim inquiry submission, please see the NaviNet Participant Guide (PDF).

Dissatisfactions or complaints/grievances from members and providers are investigated, responded to, and trended. Monthly random audits on provider appeal determinations are conducted. Trends and the results of investigations are reported to the QAPIC, which coordinates initiatives to address identified opportunities for improvement.  

Providers may use the appeals process to:

• Resolve any outstanding claims payment issues. Appeal any initial or re-credentialing denial within 60 calendar days of receiving written notification of the decision.
• Appeal of an adverse action by AmeriHealth Caritas New Hampshire, including:
  • Actions against the provider for reasons related to program integrity.
  • Termination of the provider’s agreement before the agreement period has ended for reasons other than when DHHS, New Hampshire Medicaid Fraud Control Unit, or another government agency has required the Plan to terminate the agreement.
  • Denial of claims for services rendered that have not been filed as a member appeal.
  • Violation of the agreement between the Plan and the provider.

Provider appeals must be submitted in writing, along with supporting documentation. A telephone inquiry regarding payment or denial of a claim does not constitute an appeal of the claim. Provider appeals must be filed in writing and within 60 calendar days of:

1. The date of the Plan’s notice of the adverse action to be taken, or
2. The date on which the Plan should have taken a required action but failed to do so.

Providers may submit appeals to:

AmeriHealth Caritas New Hampshire
Attn: Provider Appeals
P.O. Box 7388
London, KY 40742-7388

As part of the provider appeals process, AmeriHealth Caritas New Hampshire will take the following actions:

• Notify providers in writing of any adverse action, including a description of the basis of the adverse action and the right to appeal the adverse action.
• On request and before an appeal is filed, offer timely peer-to-peer review support to providers who receive an adverse decision. Providers may reach the Peer-to-Peer telephone line by following the prompts at 1-833-472-2264 to discuss a medical determination with a physician in the AmeriHealth Caritas New Hampshire Medical Management department. Providers must call within five business days of notification of the determination.
• Thoroughly investigate each provider appeal using applicable statutory, regulatory, contractual, and provider contract provisions, as well as clinical review guidelines.
• All pertinent facts will be investigated and considered. AmeriHealth Caritas New Hampshire’s policies and procedures will also be considered.
• Provide written notice of resolution of the provider appeal (Resolution Notice) within 30 calendar days from the date the Plan received the appeal.
• Extend the decision deadline by 30 calendar days if the Plan determines additional evidence or supporting documentation is needed from the provider, or for other good cause as determined by the Plan.
• For appeals whose decision deadline has been extended for additional information, provide written notice of resolution within 30 calendar days of receipt of the additional information requested from the provider.
• For overturned appeals, take all steps to reverse the adverse action within 10 calendar days.

State Fair Hearings

A provider may pursue a State fair hearing after exhausting the Plan’s provider appeals process or if the Plan has not adhered to notice and timing requirements. The parties to the State Fair Hearing include ACNH as well as the Provider.

A State fair hearing can be requested by completing an Appeal Request form (PDF) and submitting it to:

Administrative Appeals Unit
New Hampshire Department of Health and Human Services
105 Pleasant Street
Room 121C Concord, NH 03301

Upon Participating Provider’s request for a State Fair Hearing, AmeriHealth Caritas New Hampshire will, within three (3) business days, provide DHHS and the participating provider all documentation related to the provider appeal, including but not limited to any transcript(s), records, or written decision(s). The MCO shall appear and defend its decision before the DHHS AAU. Nothing in this manual or provider agreement shall preclude the MCO from representation by legal counsel.

The DHHS Administrative Appeals Unit will notify the Plan of State fair hearing determinations within 60 calendar days of the date of the Plan’s Notice of Resolution. AmeriHealth Caritas will be bound by State fair hearing determination and take all steps to reverse any overturned adverse action within 10 calendar days.

If a Plan provider identifies improper payment or overpayment of claims from AmeriHealth Caritas New Hampshire, the improperly paid or overpaid funds must be returned to the Plan within 60 days from the date of discovery of the overpayment. Please include the member’s name and ID, date of service and claim ID.

Providers are required to return the improper or overpaid funds by:

Calling Member Services at 1-833-704-1177 (TTY 1-855-534-6730) or writing to:

AmeriHealth Caritas New Hampshire
PO Box 7389
London, KY 40742-7389.

AmeriHealth Caritas New Hampshire offers ERAs through ECHO Health, Inc. ECHO is a leading provider of electronic solutions for payments to healthcare providers. ECHO consolidates individual provider and vendor payments into a single compliant format, remits electronic payments and provides an explanation of payment (EOP) details to providers.

To receive ERAs providers will need to include both the Plan payer ID and the ECHO payer ID 58379. Contact your practice management/hospital information system for instructions on how to receive ERAs from AmeriHealth Caritas New Hampshire under Payer ID 87716 and the ECHO Payer ID 58379.

All ECHO Health-generated ERAs and EOPs for each transaction will be accessible to download from the ECHO provider portal . If you are a first-time user and need to create a new account, please reference ECHO Health's Provider Payment Portal Quick Reference Guide (PDF) for instructions.

If your practice management/hospital information system is already set up and can accept ERAs from AmeriHealth Caritas New Hampshire it is important to check that their system includes both the Plan and ECHO Health Payer IDs.

If you are not receiving any payer ERAs, contact your current practice management/hospital information system vendor to ask if your software can process ERAs. Your software vendor is then responsible for contacting Optum/Change Healthcare to enroll for ERAs under 87716 and ECHO Health Payer ID 58379.

If your software does not support ERAs or you continue to reconcile manually, but would like to start receiving ERAs only, please contact the ECHO Health Enrollment team at 1-888-834-3511.

What is or is not included?

• Any drug product, including vaccines for adults, brand name or generic, legend or non-legend, sold or distributed by a drug manufacturer (or labeler) who participates in the Medicaid Drug Rebate Program.
• Excluded from this requirement are drugs dispensed during a hospital inpatient stay and drugs dispensed under the 340B program.

How do I bill?

All claims for outpatient medications must include the National Drug Code (NDC), NDC unit qualifier, and NDC units in addition to the HCPCS codes and HCPCS quantity. This information is required to be collected on all outpatient drug claims in order for the Department of Health and Human Services to bill manufacturers for federal rebates as permitted by the Patient Protection and Affordable Care Act (PPACA).
All claims for outpatient drugs will be validated for the presence of a(n):

1. Valid NDC.
2. NDC that corresponds to the billed HCPCS.
3. Accurate unit of measure for the NDC billed (F2, GR, ML, UN).
4. NDC quantity within appropriate FDA minimum and maximum levels.

Claims not passing all of these validation criteria will be denied.

How can I determine which drugs are included in the Medicaid Rebate Program?

The Medicaid website has detailed Medicaid Drug Rebate Program data.

What is the 5-4-2 format for NDC numbers?

All drug products have an 11-digit NDC. Some of the drug manufacturers do not follow the 5-4-2 format. Regardless, if there is a missing digit in the 5-4-2 format, a zero must be added to the beginning of one of the three number sections, whichever section is deficient, in order to bring the number into 5-4-2 claim-submitting compliance. For example:

What are the differences between medical and pharmacy billing?

Below are the primary differences between medical and pharmacy billing.

Medical claims

• Usually billed in mg.*
• One J-code represents multiple NDCs.

Pharmacy claims

• Usually billed in ml.*
• The NDC is highly specific and should match the vial administered to the member.
• The NDC must be in the appropriate 5-4-2 format to match our validation file. Refer to the 5-4-2 format explanation above.

*Therefore, the quantity billed and unit of measure qualifier will rarely match between the HCPC (J-code) and NDC. See the commonly billed J-codes (PDF) to NDC billing cross-reference guide for more information.

I need help converting J-code units to NDC. Do you have a resource?

We have created a commonly billed J-codes user guide (PDF)Opens a new window.

Once you have identified the number of J-code units you will bill, simply take these units, divide by the conversion factor —denoted as "CF" — and this will provide the appropriate number of NDC units to bill. The proper NDC unit qualifier has also been listed to ensure that this is properly selected. Let's look at a few examples below:

Example #1 pegfilgrastim

• J2505 = 6mg.
• Each syringe administered equals one J-code unit.
• Available as a 6mg/0.6mL syringe.
• The conversion factor is 1.66 so the NDC quantity is 1/1.66 = 0.6.
• The unit qualifier is "mL."

For illustrative purposes only.

Example #2 trastuzumab

• J9355 = 10mg.
• Each vial contains 440mg or 44 J-code units.
• The conversion factor is 44 so the NDC quantity is 44/44 = 1.
• Even though it is an MDV, it is listed as "Each" which is reported with the unit qualifier "UN" for unit.

For illustrative purposes only.