EDI claims submission

Use the GHP Payer ID Number (75273) when submitting claims via AllScripts, Availity or Experian. Contact the following for more information:

• AllScripts Healthcare
  800-334-8534
  www.allscripts.com
  
  
• Availity
  800-282-4548
  www.availity.com/
  
  Experian
  888-661-5657
  www.experian.com/healthcare/
  
  
• EDI Claims Submission Helpdesk

Online claim review request

• If you are an NaviNet capable provider, you’ll need to use the Claims Appeals function under Workflows for this Plan/Claims on NaviNet.net.
  
  

Paper claim research request form (CRRF)

• Use the paper claim research request form to avoid unnecessary delays in processing.
• Claims research request form (CRRF) and necessary accompanying documentation must be submitted within 60 days from the date of the Explanation of Payment (EOP).
• Any request submitted without required supportive documentation or submitted after 60 days from the date of the EOP will have the original denial upheld.
• Check off the applicable reason for the reconsideration request and include the name and telephone number of the person completing the form.
• For timely filing, submission must include proof of timely. Timely filing does not exist for Coordination of Benefits claims, please submit EOP electronically.
• Claim reconsiderations submitted using the Claim Research Request Form will be finalized within 45 days of receipt. Participating provider will be notified of GHP’s determination with a new EOP with an explanation code; and/or letter.
• Claim Research Request Forms should be mailed to the following address:

Claims Department
Geisinger Health Plan
P.O. Box 160
Glen Burnie, MD 21060

CRRF Tips

• For a quicker response, use the online claims appeals function on NaviNet.
• If unable to use NaviNet, use the claim research request form to avoid unnecessary delays in processing.
• Only submit one claim per CRRF form.
• Include claim number and date of service on the form.
• Check the appropriate boxes (i.e. COB or Claim Edit).
• Replacement and voided claims should not be submitted using the CRRF process.
  • Submit replacement claims as you would a new claim. The original claim is considered null and void and is completely replaced by the information on the replacement claim submission. Any payments made on the original claim will be retracted. Consider payments made on your replacement claim as payment in full. If the replacement claim has been denied, your original payment will not be reinstated.

• Explanation of Benefits from the primary claim can be submitted with the initial electronic claim filing.
• Coordination of Benefit (COB) claims are not subject to timely filing.
• GHP has 45 days to review and process CRRFs.
• Do not submit duplicates.
• For corrected claims filed outside of timely filing, send a CRRF.
• If within timely filing, submit electronically.
  
  

When to use a CRRF

• Authorization Denials (failure to precert services) – Only when there is a compelling reason why the provider failed to precert, and the dispute is within timely filing guidelines.
• Claim Edit Denials – Be sure to check the claim edit box on the CRRF form and attach supporting documentation
• Timely Filing Denials – Only when there is a compelling reason for why the provider failed to submit timely.
  
  

When a CRRF is not necessary

• For electronic capable providers: Claim retractions should be submitted as a complete void/cancel claim using frequency code 8 for full voids/retractions.
• If an electronic provider: Correct claims should be submitted electronically.
• Questions related to provider contracts or fee schedules should be directed to the Provider Engagement team at 800-876-5357.
• Timely Filing Denials – if no compelling reason exists.
• Authorization Denials – if no compelling reason exists.
• Tomorrow Health denials.
• Contact Tomorrow Health for general inquiries not related to a specific patient or order:

• Ordering Providers: providers@tomorrowhealth.com
• DME Providers: dmepartners@tomorrowhealth.com