Claims, Billing, and Payment

Submit claims through electronic data interchange (EDI) for faster, more efficient claims processing and payment. The AmeriHealth Caritas Next EDI payer ID number is 47073.

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 Next 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 (282-4548). Assistance is available Monday through Friday from 8 a.m. to 8 p.m. ET.

Optum/Change Healthcare

• AmeriHealth Caritas Next has re-established connectivity with 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™

This option is currently only available for providers who were registered with ConnectCenter prior to the security incident. It is not necessary to complete a new registration, and usernames will remain the same. Providers will be notified when the option for new registrations is reinstated.

To reconnect:

• Access the portal via the Claims submission link in the NaviNet provider portal or via one of the direct links below:
  • Connect Center
  • physician.connectcenter.changehealthcare.com

• 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 also provides helpful user guides to assist providers with navigating the ConnectCenter portal. To access the user guide, visit the Claims Resources section at the bottom of this page.

PCH Global

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

• Click the Sign-Up link in the upper right-hand corner.

• 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.

• When you are ready to submit claims, use the following information to search for our payer information:

  • Payer name: Next

  • P.O. Box: 7425

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 Next
Attn: Claims Processing Department
P.O. Box 7425
London, KY 40742-7425

To check your claim status, sign in to NaviNet and select Claims Status Summary under Administrative Reports, or if you need assistance, call Provider Services at 1-855-266-0219.

AmeriHealth Caritas Next 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 47073 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 clearinghouse.
• 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 275 claim 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 claim attachment transaction video for detailed instructions on this process.

General guidelines

• A maximum of 10 claim attachments are allowed per submission. Each attachment cannot exceed 10 megabytes (MB) and total file size cannot exceed 100 MB.
• The acceptable supported formats are pdf, tif, tiff, jpeg, jpg, png, docx, rtf, doc, and txt.
• The 275 claim attachments must be submitted prior to the 837. After successfully submitting a 275 claim 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
    • PWK01 segment

In addition to the Attachment Control Number, the following 275 claim attachment report codes must be reported in field 19 of the CMS 1500 or field number 80 of the UB-04.. Enter the applicable code in field number 19 of the CMS 1500 or field number 80 of the UB04, as documented in the Claims and Billing Manual (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 five claims via phone at 1-833-301-3377.

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 Claims Investigation User Guide (PDF).

A complaint is a request from a health care provider to change a decision made by the plan related to claim payment; policy, procedure, or administrative functions; or denial for services already provided. A provider complaint is not a pre-service appeal of a denied or reduced authorization for services or an administrative complaint.

Examples include, but are not limited to:

• Credentialing concerns, such as timeliness, allegation of a discriminatory practice, or policy.

• Claim-related issues, including inaccurate payment, claim denials, and post-service authorization denials.

• Service issues with the plan, including failure by the plan to return a provider's calls, frequency of site visits, and lack of provider network orientation and education.

Claim disputes

Providers who receive an unsatisfactory response to a claim investigation may submit a claim dispute within 60 days of the date of the denial by downloading the Claims Dispute Form (PDF) from the forms section of our website and submitting  the request, along with any supporting documentation, in writing to:

AmeriHealth Caritas Next
Attn: Provider Claim Processing
P.O. Box 7425
London, KY, 40742-7425

If a claim or a portion of a claim is denied for any reason or underpaid, the provider may file a complaint about the claim within 365 days from the date of service. A telephone inquiry regarding payment or denial of a claim does not constitute a complaint of the claim.

Please note: Please include the member’s name and ID, date of service and claim ID.

Standard appeals

The member or their authorized representative can file an appeal of an Adverse Benefit Determination verbally by calling Member Services at 1-833-590-3300 (TTY 711) or in writing to:

Member Appeals Department
AmeriHealth Next
P.O. Box 7430
London, KY, 40742-7430

An appeal must be filed within 180 days from the date of our written notice denying the member’s claim or the member’s request for service.

Refunds for improper payment or overpayment of claims

If a plan provider identifies improper payment or overpayment of claims from the plan, the improperly paid or overpaid funds must be returned to the plan within 60 days. Providers are required to return the identified funds to the plan by submitting a refund check directly to the provider claims processing team as outlined in our Provider Manual:

Per chapter 27, section 2730 of the Delaware Code, other than recovery for duplicate payments, AmeriHealth Caritas Next, whenever it engages in overpayment recovery efforts, will provide written notice to providers that identifies the error made in the processing or payment of the claim and justifies the overpayment recovery.   AmeriHealth Caritas Next will provide the provider with the opportunity to challenge an overpayment recovery, including the sharing of claims information, and will establish written policies and procedures for providers to follow to challenge an overpayment recovery.

AmeriHealth Caritas Next will not initiate overpayment recovery efforts more than 24 months after the original payment for the claim was made. No such time limit will apply to overpayment recovery efforts which are:

• Based on a reasonable belief of fraud, abuse, or other intentional misconduct.

• Required by, or initiated at the request of, a self-insured plan; or

• Required by a state or federal government plan.

AmeriHealth Caritas Next
Attn: Provider Claim Processing
P.O. Box 7425
London, KY, 40742-7425

Please note: Please include the member’s name and ID, date of service, and claim ID.

AmeriHealth Caritas Next offers ERAs through ECHO Health, Inc. ECHO is a leading provider of electronic solutions for payments to health care 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 Next under Payer ID 47073 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 Next 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 Payer ID 47073 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.

• Access the Claims and Billing Manual (PDF)
  Use this guide to help avoid common claim errors and delays in the processing of your claims.