Claims submission

Claims submission

Claim attachments

Learn more about when, and how, to submit claim attachments.

Claims edits

If you do not submit your claims through the Availity Provider Portal, follow this process to submit your claims to us electronically.

Coding toolkit

Learn more about our customized editing rules, including clinical edits, bundling edits, and outpatient code editor.

Modifiers

Learn more about informational, preventive services and functional modifiers.

Benefit coordination

Coordination of Benefits, Medicare crossover and other party liability or subrogation.

Medication claims

Learn how to submit claims for medications provided in your office.

Dental billing

Tips to ensure your dental claims are processed quickly and correctly.

Behavioral health records

Tips for treatment record keeping, chart notes and clinical documentation.

Office staff job tools

Tools to help you understand our clinical edits, invalid codes and administrative simplification.

Other billing information

View additional claims and other billing tips.

Claims submission

Our participating providers and facilities agree to bill us directly for covered services provided to our members in accordance with their participating agreement.

All providers that are eligible to contract with Asuris must bill for all services they perform under their own name. A provider may not submit claims for services performed by another provider that is eligible to contract. We do not accept claims from unlicensed providers completing a residency or internship submitted under their name or under the attending or supervising provider.

Once coverage is verified, patients should not be asked for full payment or coinsurance amounts at the time of service.

  • Patients may be asked for copayments and deductibles, or they may elect to pay their coinsurance at the time of service.
  • After services are rendered, the patient should only be billed for any remaining deductible, copayment and/or coinsurance amounts not collected and non-covered services.

Centers for Medicare & Medicaid Services (CMS) provides regulations and guidance on correct billing and coding use.

Electronic claims submission

We require all medical and dental claims to be submitted electronically.

Electronic claims may be submitted through many types of practice management software systems or via Internet file transfer protocol (FTP). Contact the billing service or claims clearinghouse of your choice to enroll.

You can key and submit single electronic claims or submit multiple claims via electronic batch transactions. Contact your billing service/clearinghouse to see what options they can provide.

We currently accept the following ANSI v5010 transactions:

Type

Description

Contact information

270/271

Eligibility Request and Response

Contact Availity

276/277

Claims Status Inquiry and Response

Contact Availity

277CA

Health Care Claim Status Acknowledgement

No enrollment needed, submitters will receive this transaction automatically

278

Web portal only: Referral request, referral inquiry and pre-authorization request

Contact Availity

835

Remittance Advice

Contact Availity

837

Health Care Claim

Contact Availity

999

Implementation Acknowledgement for Health Care Insurance

No enrollment needed, submitters will receive this transaction automatically

TA1

Interchange Acknowledgement

No enrollment needed, submitters will receive this transaction automatically

Note: Availity supports business-to-business (B2B) integration for eligibility and benefit inquiry transactions. Contact your practice management system vendor and ask if they support B2B transactions with Availity for Asuris, or view the Availity technology partners list.

Availity Provider Portal

In addition to the electronic transactions you may already submit through the Availity Portal, with a single sign-on you can access multiple payers, including Asuris, to check member eligibility and benefits, submit claims and many other services. Register today.

Paper claims submission

Paper claims are only accepted when they are submitted by our member. Paper claims submitted by providers will be returned for electronic submission.

Paper claims must be submitted on appropriate claim forms and mailed to the applicable address.

Claims are generally processed within 14 days after receipt. However, some claims requiring investigation may take longer.

If you do not receive notification of a processing action on a claim within 45 days please verify status using the Availity Portal. If no record is found, please resubmit the claim.

Requirements

All participating providers and any provider who practices in our service area must submit their medical and dental claims electronically.

ICD coding use

All International Classification of Disease (ICD) coding must be coded to the highest level of specificity that is known at the time of each health care encounter.

Specific diagnosis codes should be reported when they are supported by the available patient's medical record documentation and clinical knowledge of the health condition, however, there are situations when signs/symptoms or unspecified codes are the best choices for accurately reflecting the health care encounter as indicated below:

  • It is appropriate to report codes for sign(s) and/or symptom(s) if a definitive diagnosis has not been established by the end of the patient encounter, in lieu of a definitive diagnosis.
  • Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient's condition at the time of that encounter.

Taxonomy codes

Providers may have multiple taxonomy codes and should only include the taxonomy code that applies to the services performed and reported on the claim submission.

For electronic submission, report the taxonomy code for the service provided in the HIPAA v5010 837 P, I and D claims PRV segment. Please note:

  • A taxonomy code must be valid
  • If you send a rendering provider loop, include the PRV at the 2310B level. If no rendering provider loop, include the PRV at the 2000A level

Taxonomy codes are national specialty codes used by providers to indicate their specialty or provider type on a claim. When applying for a National Provider Identifier (NPI), you choose your provider taxonomy code(s). The Washington Publishing Co. publishes the various provider specialty designations with their corresponding taxonomy codes.

Taxonomy codes indicated at the time of your NPI application are reflected on the confirmation notice document received from the National Plan and Provider Enumeration System (NPPES) along with the provider's assigned NPI number. Current taxonomy code(s) registered with NPPES may be obtained on an inquiry basis by visiting the NPI Registry website.

View all the Health Care Provider Taxonomy Code sets.

Corrected claims

A corrected claim is any claim that has a change to the original claim (e.g., changes or corrections to charges, procedure or diagnostic codes, dates of service, member name, etc.) Submit the corrected claim electronically as soon as the error is identified.

Claims correction should be submitted in an electronic format.

  1. In the 2300 Loop, the CLM segment (claim information), CLM05-3 (claim frequency type code) must indicate one of the following qualifier codes:
    • "7" – REPLACEMENT (Replacement of Prior Claim)
    • "8" – VOID (Void/Cancel of Prior Claim)
  2. The 2300 Loop, the REF segment (Claim Information), must include the original claim number issued to the claim being corrected. The original claim number can be found on your electronic claims receipt confirmation reports or electronic remittance advisement.

Medical records requests

If we determine, during processing, that medical records are needed to adjudicate a claim, that claim will be closed and we will send you a letter requesting the specific medical records required. Upon receipt of the records, we will complete our review and process the claim.

Your remittance advice will include the following Claim Adjustment Reason Code (CARC), Remittance Advice Remark Code (RARC), CARC/RARC code:

  • M127: Missing patient medical record for this service
  • 252: An attachment/other documentation is required to adjudicate this claim/service. At least one Remark Code must be provided (may be comprised of either the NCPDP Reject Reason Code or RARC that is not an ALERT)

If your office is unable to send requested medical records to us via fax or mail, view these steps to submit medical records (PDF) for provider appeals and clinical audits using a secure file transfer protocol (SFTP) site. For provider appeals, you can also use the SFTP site to upload your appeal request and supporting documentation.

Notes:

  • Do not resubmit the claim.
  • A claim that is closed for chart notes is not eligible for appeal.

Timely claims filing and adjustments

The following policy for timely submission of claims applies to all types of participating providers and hospitals across all lines of business, including government programs. If the timely claims filing guidelines below are inconsistent with the terms of your participating agreement, the terms of your agreement will prevail.

  • Original claims must be submitted in accordance with the terms set forth in your participating agreement.
  • Any adjustments to the original claim must be submitted within 24 months of the last process date or denial notice.

To submit a timely claims filing exception request, mail the documentation to support the exception, along with the claim number, to our correspondence address.

Notes:

  • Other party liability adjustment (OPL) by Asuris are exempt from timely filing guidelines.
  • We will accept an external request to adjust a claim outside the above limits if the adjustment does not result in additional payment.

Coordination of benefits timely claims filing and adjustments

Coordination of Benefits (COB) claims must be submitted within one year of the date of service. Any adjustments to COB claims must be submitted within 30 months of the last process date or denial notice.

Refund and adjustment timelines

Coordination of Benefits (COB) claims must be submitted within:

  • Commercial: 30 months from the original process date
  • Medicare: 24 months from the original process date

NPI

Please include your national provider identifier (NPI) number and your tax identification number (TIN) on all claims. Both numbers are needed to ensure accurate claims processing and payment. If you do not have an NPI, please follow the steps below:

  1. Obtain your NPI
    If you have not applied for your NPI, complete either a paper form or an online application available on the National Plan & Provider Enumeration System (NPPES) website. The Centers for Medicare & Medicaid Services offers enumeration guidelines and many other NPI-related resources.

Dental providers: We cannot deliver your 835 ERAs without a "Pay to" NPI.

If the answer to either question below is "no", please contact your dental provider experience representative and provide the NPI needed.

  • I am provider who is paid directly. Does Asuris have my NPI?
  • I am a provider who is part of group/corporation and payment is directed to that group. Does Asuris have that NPI?

  1. Submit your NPI to us by completing our Provider Information Update Form.