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Claims

You can file claims with us electronically or through the mail. We work to streamline the way we process claims. And improve payment turnaround time, so you can save time and effort. 

 

Questions?

Check out your provider manual (PDF). Or call Or call Provider Relations at at 1-800-279-1878 (TTY: 711). We’re here for you Monday through Friday, 8 AM to 6 PM.

Fee schedules and billing codes

 

You can find the billing codes you need for specific services in the fee schedules.

 

Fee schedule

You’ll need to fill out a claim form.

 

You must file claims within 365 days from the date you provided services, unless there’s a contractual exception. For inpatient claims, the date of service refers to the member’s discharge date. You have 365 days from the paid date to resubmit a revised version of a processed claim. 

 

All claims must be submitted with this information:

 

  • Member’s name, date of birth and ID number
  • Type of service
  • Date and location of service

 

Online

 

You can submit claims or resubmissions online through ConnectCenter using payer ID: 128VA. This is our provider claims submission portal via Change Healthcare (formerly known as Emdeon). To register, visit the ConnectCenter portal and follow the prompts to “Enroll New Customer.”

 

ConnectCenter portal

 

Once you’ve submitted claims, you can visit the Provider Portal to review claims payment information.

 

By mail

 

You can also mail hard copy claims or resubmissions to:

 

Aetna Better Health® of Virginia

P.O. Box 982974 

El Paso, TX 79998-2974

 

Mark resubmitted claims clearly with “resubmission” to avoid denial as a duplicate. 

 

Mark resubmitted claims clearly with “resubmission” to avoid denial as a duplicate. 

 

CMS-1500 sample (PDF)

 

To see a sample of a UB-04 form, check your provider manual (PDF).

You can resubmit a claim through ConnectCenter or by mail.

 

If you resubmit through the ConnectCenter portal, you’ll need to mark your resubmission with a number for the frequency code:

 

  • "7” for replacement or adjustment claims
  • “8” for voided claims

 

If you resubmit by mail, you’ll need to include these documents:

 

  • Claim resubmission/reconsideration form (PDF)
  • An updated copy of the claim — all lines must be rebilled
  • A copy of the original claim (reprint or copy is acceptable)
  • A copy of the remittance advice on which we denied or incorrectly paid the claim
  • A brief note describing the requested correction
  • Any other required documents

Both in-network and out-of-network providers have the right to appeal the result of a decision. You’ll want to file your appeal in writing within 60 calendar days of the reconsideration response (date of EOB).

 

You'll get a final determination letter with the appeal decision, rationale and date of the decision. We usually resolve provider appeals within 30 calendar days.

 

If the appeal decision isn’t in your favor, you can’t “balance bill” the member for services or payment that we denied for coverage. 

 

You can file an appeal:

 

By phone

 

Just call us at 1-800-279-1878 (TTY: 711) 

 

By mail

 

You can send your appeal to:

 

Aetna Better Health of Virginia

PO Box 81040

5801 Postal Road

Cleveland, OH 44181

 

By fax

 

Fax your appeal to 1-866-669-2459.

 

By email

 

Email us your appeal.

 

Learn more about claim appeals

A claim reconsideration is a request that we previously received and processed as a clean claim. It’s a review of a claim that a provider believes was paid incorrectly or denied due to processing errors.

 

When you send a reconsideration, be sure to include:

 

  • A claim form for each reconsideration
  • A copy of the remit/Explanation of Benefits (EOB) page for each resubmitted claim, with a brief note about each claim you’re resubmitting
  • Any information that the health plan previously requested

 

You can file a claim reconsideration by mail:



Mail your reconsideration form (PDF) and all supporting documents to:

 

Aetna Better Health of Virginia

Attn: Reconsiderations

P.O. Box 982974 

El Paso, TX 79998-2974

Electronic funds transfer (EFT)

EFT makes it possible for us to deposit electronic payments directly into your bank account. You can get an EFT form here or on our Provider Portal. Some benefits of setting up an EFT include:

 

  • Improved payment consistency
  • Fast, accurate and secure transactions

 

Once you complete the EFT form, you can send it by:

 

 

ETF form (PDF)

 

You’ll want to allow up to 15 days for us to process your EFT form. Once processing is complete, we’ll send you a confirmation letter.

 

Provider Portal

Electronic remittance advice (ERA)

ERA is an electronic file that contains claim payment and remittance info sent to your office. The benefits of an ERA include:

 

  • Reduced manual posting of claim payment info, which saves you time and money, while improving efficiency 
  • No need for paper Explanation of Benefits (EOB) statements
 
Once you complete the ERA form, you can send it by:
 

 

ERA form (PDF)

 

You’ll want to allow up to 15 days for us to process your ERA form. Once processing is complete, we’ll send you a confirmation letter.

 

Provider Portal 

Helpful resources

Check out these answers to common questions about claims.

 

How much claim history is available online?

Three years, depending on the plan.

 

What Medicaid plan information am I able to see?

Claim Inquiry information includes claim summary, history and detail, just as it appears for commercial plans. Member Eligibility information includes coverage history, PCP (primary care provider) history and COB (coordination of benefit) details, if available. Remittance advices are available. However, benefit information is not available for Medicaid members.

 

How are offsets and backouts shown on the claims status?

Backout claims (claims that have a negative balance) are associated with a specific claim and are only available by clicking or searching on the original claim associated with the backout. Claim Detail gives you the option to see the original claim, backout claim and/or replacement claim. The claim type is identified at the top of the claim.

 

What is the Patient Control Number?

The Patient Control Number is the medical record number we receive from the provider associated with the claim.

 

I currently see "Unpaid Claims" in addition to other statuses. Is this OK?

"Unpaid Claims" isn’t a claims status. It’s a search option which shows all claims that do not yet have a check or EFT payment associated with it. Keep in mind that an approved status may eventually get denied or pended; it’s not a guarantee of payment.

 

Do claims include the rejected claims from our clearinghouse or where they are rejected from?

No, you won’t be able to see claims rejected at the clearinghouse since we don’t receive them. The rejected claims you can see online are ones that are rejected by us, after they passed through the clearinghouse. If you submitted your claim directly to us, without going through a clearinghouse, then they’ll all appear. An example of a rejection is “patient not found.”

 

Can I submit claims directly through the Provider Portal?

Claims submission through the Provider Portal will be available in the future, but not right now.   

 

Why do some claims allow you to view the Remittance Advice and not others?

It depends on who the claim was paid to. If you’re viewing a claim under a provider ID that didn’t receive payment for that claim, then the remittance advice link won’t appear with that claim. To view the remittance advice, look up the remittance advice under the appropriate provider ID it was paid to.

 

Can claim adjustments be requested online?

Yes. This service allows a provider to request that the plan take another look at a claim based on additional information, including attachments that can be sent through the Provider Portal. However, it’s not a formal appeal.

 

I submitted a claim to the health plan. It was paid, but I cannot find it now. What do I do?

We internally route claims to the correct payer, even if the claim was submitted to the incorrect health plan. If you submitted the claim to the incorrect payer ID and it can’t be found, you should check under another Aetna Better Health plan you do business with. Also, review your remittance advice for any information on the re-routed claim. 

 

Where do I mail my paper claims?

You can mail your paper claims to:

 

Aetna Better Health of Virginia
Attn: Claims
P.O. Box 982974 
El Paso, TX 79998-2974

RC Claim Assist from RJ Health

 

This online resource helps improve the process for submitting pharmacy claims. Using a self-service platform, providers can easily convert HCPCS/CPT (Healthcare Common Procedure Coding System/Current Procedural Terminology) drug code units to NDC drug code units.

 

RC Claim Assist helps providers and the overall claims process by:

 

  • Providing a broad crosswalk of HCPCS/CPT drug codes, product names and NDCs
  • Reducing the number of resubmissions for claims payment
  • Offering complete drug information on package size billable units
  • Aligning providers and payers on managing medically covered pharmaceuticals

 

How to get started

 

  • Visit the RC Claim Assist website.
  • Register to complete a brief registration process.
  • Enter your NPI (National Provider Identifier).
  • Enter your first and last name.
  • Create your password.

 

Once you’ve completed registration, you can log in and start using the services. 

 

What are the billing requirements for NDC?

You can find these details in your provider manual (PDF).

 

What if an NDC is no longer active?

When billing with NDCs on claims, you’ll want to ensure that the NDC used is valid for the date of service. This is because NDCs can expire or change. An NDC’s inactive status is determined based on a drug’s market availability in nationally recognized drug information databases.

 

Additionally, an NDC is considered no longer in use two years after its inactive date. We recommend that you do a routine check of records or automated systems where NDCs may be stored in your office for billing purposes. To help ensure that correct reimbursement is applied, the 11-digit NDC on your claim should correspond to the active NDC on the medication’s outer packaging. Inactive products will continue to be reimbursed until they are no longer in use.

 

Questions about RC Claim Assist?

You can email RJ Health directly. For questions on a specific claims issue, just email us.

Also of interest: