The Claims Department at Virginia Premier is committed to providing you with the highest level of service possible. Our mission is to pay claims correctly and quickly the first time. Doing it right the first time saves time and money for everyone. We want to help you improve the premier health outcomes of our members by reducing the time you spend on claims follow-up.
The Claims Department at Virginia Premier is committed to providing you with the highest level of service possible. Our mission is to pay claims correctly and quickly the first time. Doing it right the first time saves time and money for everyone. We want to help you improve the premier health outcomes of our members by reducing the time you spend on claims follow-up.
If you have questions for the Claims Department or suggestions on how we can improve our operations, please call us at 800-727-7536, press 4 for Claims. Our fax number is 804-819-5174.
No. Per the National Uniform Claim Committee (NUCC):
In order for the form to be read by a scanner, the form must be in red ink. The red ink that is specified for the form allows scanners to drop the form template during the imaging of the paper. This “cleaner” image is easier and faster to process with data capture automation such as ICR/OCR (Intelligent Character Recognition/Optical Character Recognition) software. Your vendor may choose not to process claim forms that are submitted in black ink.
As of 6/15/13, Virginia Premier requires all providers performing lab services to submit a CLIA certificate number on both electronic and paper claims. The CLIA Certificate number should be populated in box 19 of the CMS 1500 form or in Loop 23 Segment REF X4 for electronic claims. Submitting a CLIA number is a federal requirement and failure to provide the require information will result in the denial of a claim and payment.
No. All claims submitted must be computer generated or typed to ensure accurate processing. All required fields and appropriate procedure/diagnosis codes must be accurate on the claim form in order to be considered a clean claim.
Note: Handwritten claims are subject to be denied or returned.
A “clean claim” is defined as a claim that has no material defect or impropriety (including any lack of any reasonably required substantiation documentation) which substantially prevents timely payment from being made on the claim or with respect to which Virginia Premier has failed to timely notify the person submitting the claim of any such defect or impropriety.
If you are a provider type where a NPI number is required, failure to include your NPI number on the claim could result in the claim being denied or rejected.
If you are a provider type where NPI is not required, contact our Claims department for information on receiving an Atypical Provider Identification (API) number.
The number of units should always equal the actual number of days the equipment is rented. For example, when spanning dates of service such as, 11/1/13 – 11/30/13, the number of units should be “30”.
Please refer to the DMAS Appendix “B” for more information on billing units.
All denied claims must be appealed in writing to Virginia Premier Health Plan, Inc. within sixty (60) days of the original date of denial.
The “appeal claim” must include any supporting documentation, which explains or satisfies the reason for the original denial and why it should be paid accordingly.
Non-medical denials (e.g. timely filing, duplicate claim, cannot ID member, triage payment etc.) should be appealed to:
Virginia Premier Health Plan, Inc. Attention Appeals Department
P. O. Box 5286
Richmond, Virginia 23220-0286
Claims denied for medical reasons (e.g. not medically necessary, etc.) must be appealed to Virginia Premier Health Plan, Inc. Medical Management Department with medical record documentation at:
Virginia Premier Health Plan, Inc. Attention Medical Management Department
P. O. Box 5244
Richmond, Virginia 23220-0244
Some claim denials do not require an appeal and can be resolved by correcting the issue and simply refilling the claim. Examples include:
Not Authorized: Re-file the claim with the correct authorization number
Invalid or Expired CPT Code: Correct the code(s) and re-file the claim
Invalid or Expired Diagnosis Code: Correct the code(s) and re-file the claim
The Appeal Claims form can be accessed in the Claims section of the Provider Forms Library
If you change your tax identification number, address, NPI #, legal business name or any other contractual changes please forward a W-9 along with your changes to your Contracting Representative immediately.
Doing this can avoid possible IRS regulated fines and/or withholdings from your claim, capitation and/or management fee payments.
In addition, any changes made without a W-9 attached will delay payment of any of your claims.
If your Remittance Advice is less than 60 days old, please call us to obtain a copy of your Remittance.
For Remittances older than 60 days, we can create, upon request, a custom report with the data you need. Please call the Claims Department at 800-727-7536, option 4 for assistance.
Payments are usually processed every Friday and are mailed out by the following Wednesday of each week.
Delays from the Friday pay date are usually due to holidays.
Please check with the Claims department to ensure the claim you are seeking payment for has been processed for payment. You can contact the Claims department at 800-727-7536, option 4.
If you receive your payments via electronic funds transfer, you should receive your payment within 2 business days from Friday. Check with your banking institution as all payments are paid from our account on Friday.
To change bank account information complete the EFT Change form, located in the Claims section of the Provider Forms Library, and send it in as instructed.
If you have questions for the Claims Department or suggestions on how we can improve our operations, please call us at 800-727-7536, press 4 for Claims. Our fax number is 804-819-5174.
Virginia Premier CompleteCare (Medicare-Medicaid Plan) Providers
Below is a list of resources to help with submitting claims:
API Claims Submissions: CompleteCare– We want to make the process as easy as possible. Learn about the portal and who to contact to get started here.
Clearinghouses: CompleteCare– Virginia Premier is pleased to be partnering with two of the largest clearinghouses in the industry to provide a full range of electronic capabilities for our CompleteCare providers and network partners.
CompleteCare Companion Guide– Instructions related to 837 Health Care Institutional & Professional Claims Transaction Based on ASC X12 Implementation Guides
Virginia Premier Health Plan (Medallion 3.0) Providers
Below is a list of Virginia Premier claim filing addresses:
PCP Claims PO Box 5207
Richmond, VA 23220-0207
Specialty Claims PO Box 5208
Richmond, VA 23220-0208
Hospital Claims PO Box 5120
Richmond, VA 23220-0120
Transportation Claims PO Box 5287
Richmond, VA 23220-0287
Virginia Premier strongly encourages our providers to file their claims electronically. By filing claims electronically, you are able to aid in lowering claims processing timeframes, which in turn allows Virginia Premier to make payments more quickly.
EDI 837 Claims
Please refer to the first document below for instructions on how to send EDI 837 (electronic) claims to Virginia Premier Health Plan, Inc. You will find answers to most of your questions here.
The EDI 837 (Electronic Claims Enrollment) form can be found in the Claims section of the Provider Forms Library.
EDI 835 ERA
Should you want to receive the EDI 835 ERA (Electronic Remittance Advice) from Virginia Premier, the process is exactly the same as the process to send electronic claims to Virginia Premier. Only the form is different.
The EDI 835 (Electronic Remittance Advice) form can be found in the Claims section of the Provider Forms Library.
Other EDI Transactions
Virginia Premier also offers additional transactions in partnership with our clearinghouses. If interested in either of the following, please contact your clearinghouse.
