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Questions?
Check out your provider manual (PDF). Or call Or call Provider Relations 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.
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
- Billing and/or rendering provider taxonomy codes that are consistent with the provider’s registered specialty with DMAS
NPI (not required for atypical providers) - Practice address
- Billing address
For more information, visit Chapter 13 of our provider manual.
Make sure you are enrolled as a provider through the Virginia MES Provider Portal.
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 “Sign Up” and enter Vendor Code 214557.
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.
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.
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) and electronic remittance advice (ERA)
EFT makes it possible for us to deposit electronic payments directly into your bank account. You can get start setting up EFT here or on our Provider Portal.
Some benefits of setting up an EFT include:
- Improved payment consistency
- Fast, accurate and secure transactions
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
Aetna Better Health has partnered with Change Healthcare to offer EFT/ERA Registration Services (EERS), a better and more streamlined way for our providers to access payment services. EERS offers a standardized method of electronic payment and remittance that expedites the payee enrollment and verification process. Providers can use the Change Healthcare tool to manage ETF and ERA enrollments with multiple payers on a single platform.
How does it work?
EERS will give payees multiple ways to set up EFT and ERA in order to receive transactions from multiple payers. If a provider’s tax identification number (TIN) is active in multiple states, a single registration will auto-enroll the payee for multiple payers. Registration can also be completed using a national provider identifier (NPI) for payment across multiple accounts. Providers who currently use Change Healthcare as a clearinghouse will still need to complete EERS enrollment, but providers who currently have an application pending with Change Healthcare will not need to resubmit. Once enrolled, payees will have access to the Change Healthcare user guide to aid in navigation of the new system.
How and when do I enroll?
All Aetna Better Health plans will migrate payee enrollment and verification to EERS.
For questions or concerns, reach out to Provider Relations or visit the Change Healthcare FAQ page
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 contact us.