Providers

Claims

Last Updated: December 1, 2022 at 10:24 pm

Claim Submissions and Coordination of Benefits

Where should Plan Providers send their Claims?

BCBSAZ Health Choice Pathway
Attn: Reimbursement Services
P.O. Box 52033
Phoenix, AZ 85072-2033

What is BCBSAZ Health Choice Pathway’ Payor ID#?

Our payor ID# is 62180.

Which Provider ID # should be used on the Claim Form for BCBSAZ Health Choice Pathway

Providers may use their Medicare/UPIN number in Box 33 or continue to use the AHCCCS Provider ID as currently used when billing Health Choice.

Effective January 1, 2007, Health Choice will allow the option to submit claims using the National Provider Identifier (NPI), however, effective May 23, 2007, all claims are required to submitted with the NPI. More information on NPI is available online at Centers for Medicare and Medicaid Services.

Providers currently contracted with Health Choice may mail or fax written notification of their NPI number to the Network Services.

BCBSAZ Health Choice Pathway
Attention: Network Services
410 N. 44th Street, Ste. 900
Phoenix, AZ 85008

Maricopa and Pinal Counties Fax: 480-303-4433
Pima County Fax: 520-322-5784
Apache/Navajo/Coconino Counties Fax: 928-532-0824

How may I check Claims Status or Claims Inquiry?

Providers can visit the BCBSAZ Health Choice Pathway Web site to review claims and check member eligibility. Providers must pre-register on-line prior to having access to this confidential information. After you have registered, you will be able to view only your member’s claim information. Should you have difficulty registering you may refer to the Log-in Tutorial.

Providers may also call BCBSAZ Health Choice Pathway Claims Customer Service or Member Services for eligibility at 1-800-656-8991, TTY 711, 8 a.m. – 8 p.m., 7 days a week.

Who is the Primary payor: BCBSAZ Health Choice Pathway or Health Choice Arizona?

BCBSAZ Health Choice Pathway (Medicare) is the primary payor and submits the encounter directly to Health Choice Arizona (Medicaid) for processing of the secondary payment. Providers do not have to submit two claims to each Plan. However, Providers will receive two explanation of Benefits (EOB), one EOB reflects the Medicare allowable and the second EOB will show processing of any secondary amount under the Medicaid (AHCCCS) program. If Health Choice Arizona is not the secondary payor, then the primary EOB must be submitted to the secondary payor by the Provider.

Provider Accounts Receivable

Health Choice does not reconcile accounts receivable for provider offices. It is the responsibility of the provider office to ensure that payments are properly posted and that claims are resubmitted with proper/requested information in a timely manner. Enclosed is a BCBSAZ Health Choice Pathway denial glossary to assist you in reconciling your receivables.

Timely filing:

NON-CONTRACTED PROVIDERS:
Initial Claim:
12 months from the date of service.
Corrected Claim: 12 months from the date of service.

CONTRACTED PROVIDERS:
Initial Claim:
6 months from the date of service.
Corrected Claim: 18 months from the date of service.

Timeliness NON-CONTRACTED CONTRACTED
Claim Submissions 12 Mos from DOS (end) 6 Mos from DOS (end)
Claim Re-submission 12 Mos from DOS (end) 18 Mos from DOS (end)
Dispute 120 Days from the Date of Claim Determination 18 Mos from DOS (end)
Second Level Dispute Health Plan forwards to IRE 60 Days after the Decision
OR
18 Mos from DOS (end)

 

Resolving claims issues for BCBSAZ Health Choice Pathway Providers.

BCBSAZ Health Choice Pathway would like to assist you in resolving your claims issues.

If you are a BCBSAZ Health Choice Pathway Contracted Provider:

If a claim is denied or you disagree with a payment:
Please call our Member Services Department at 1-800-656-8991. The Member Services Representative (MSR) will review the claim issue with you and send a referral sheet if an adjustment is required. This referral will be routed to the BCBSAZ Health Choice Pathway Claims Team Lead for research and determination.

The claim in question must be timely (1-year from the date of service or 60-days from the date of last adverse action).

If the claim is paid correctly and no adjustment is necessary, then a new line will be entered under the same claim number and a note will be entered detailing the findings of the research.

If the claim is paid/processed incorrectly, then an adjusted line will be added for each claim line that is paid incorrectly. A note will be added to the claim detailing the adjustment and indicated if an additional payment will be made or if recoupment for an overpayment is needed.

If you require a call back from the adjuster regarding the determination, please make the request when speaking with the Member Service Representative.

If you are NOT a BCBSAZ Health Choice Pathway Contracted Provider:

Non-contracted providers are permitted to file a standard appeal for a denied claim only if you complete a Waiver of Liability Statement (WOL), which provides that you will not bill our member regardless of the outcome of the appeal. The WOL Statement is available on our website or by calling BCBSAZ Health Choice Pathway at 1-800-656-8991. Corrected claims should not be submitted as an appeal. They are considered a new claim and should be sent to the Reimbursement Services Department for an Initial Organization Determination.

New claims should be mailed to:
BCBSAZ Health Choice Pathway
Attn: Reimbursement Services
P.O. Box 52033
Phoenix, AZ 85072-2033

A Standard Appeal may be filed for payment requests by utilizing the following steps.

  • A Provider may request a standard reconsideration by filing a signed, written request with BCBSAZ Health Choice Pathway within 60 calendar days from the date of denial. This request must be accompanied by a WOL Statement, name of the member, information identifying which denial is being appealed, and contact information for the appellant. If the WOL Statement is not provided, then every effort will be made by BCBSAZ Health Choice Pathway to obtain it. If the WOL Statement is not received within 60 calendar days, then the request for reconsideration will be forwarded to the Independent Review Entity (IRE) with a request for dismissal.
  • BCBSAZ Health Choice Pathway will mail an acknowledgment letter to the non-contracted provider within 5 calendar days of receipt.

    Mail requests to:

    BCBSAZ Health Choice Pathway
    Attn: Provider Appeals
    P.O. Box 52033
    Phoenix, AZ 85072-2033

  • Once the request for expedited or standard reconsideration is received and logged, you may be contacted to provide additional information in order to review the case. BCBSAZ Health Choice Pathway must contact you within 24 hours of the initial request for an expedited reconsideration if additional information is needed.
  • BCBSAZ Health Choice Pathway will make its reconsideration determination as expeditiously as the enrollee’s health condition requires, but no later than 72 hours (or up to 17 days with an extension) after the request for an expedited reconsideration, no later than 30 calendar days from the date it received the request for a standard pre-service reconsideration and no later than 60 calendar days from the date it receives the request for a standard payment reconsideration.
  • If you require a call back from the adjuster regarding the determination, please indicate so when speaking with Member Services so it may be noted on the referral.
  • If upon reconsideration, BCBSAZ Health Choice Pathway overturns its adverse organization determination denying a request for payment, then BCBSAZ Health Choice Pathway will issue its reconsidered determination and send a payment for the service no later than 60 calendar days from the date it received the request for a standard reconsideration.
  • If BCBSAZ Health Choice Pathway affirms, in whole or in part, its adverse organization determination, you will be notified in writing and a case file will be prepared and sent to the Independent Review Entity (IRE) contracted by CMS.
  • If the IRE reverses the original determination then payment will be made within 30 calendar days from the date BCBSAZ Health Choice Pathway receives the notice of the reversal.
  • If the IRE affirms the original determination, and the amount remaining in controversy meets the appropriate threshold requirement ($160.00 in 2018) then the provider or beneficiary has a right to a hearing before an Administrative Law Judge (ALJ).

The Request for Hearing must be in writing and must be filed with the entity specified in the IRE’s reconsideration notice within 60 days of receiving the adverse determination.

Getting a National Provider Identifier (NPI)

It’s every provider’s responsibility to make sure that an NPI is obtained if the provider is required to do so. If you’re not sure, it’s time to investigate.

Health care providers can apply for National Provider Identifiers (NPI) in one of three ways:

  1. For the most efficient application processing and the fastest receipts of NPIs, health care providers should consider using the web-based NPI application process. They can log onto The National Plan and Provider Enumeration System (NPPES) and apply online.
  2. Health care providers can agree to have an Electronic File Interchange (EFI) organizational submit application data on their behalf (i.e. through a bulk enumeration process)
  3. Health care providers may wish to obtain a copy of the paper NPI Application/Update Form (CMS-10144) and mail the completed, signed application to the NPI Enumerator located in Fargo, ND, whereby staff and the NPI Enumerator will enter the application data into NPPES.

The form will be available only upon request through the NPI Enumerator. Health care providers who wish to obtain a copy of this form must contact the NPI Enumerator in any of these ways:

Phone: 1-800-465-3203 TTY/TTD users call 711
E-mail: customerservice@npienumerator.com
Mail: NPI Enumerator P.O. Box 6059 Fargo, ND 58108-6059


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