Payment

Receiving payment

Professional reimbursement

Learn about our professional reimbursement methodology.

Overpayment recovery

Payments are occasionally recouped due to a duplicate or adjusted claim. View instructions for responding to a recoupment request.

Appeals

Our appeals process includes adverse determinations, external audit and investigation, provider contract termination and medical or reimbursement policy reconsideration.

Payment vouchers

Our remittance advices are generated weekly and include information about how your claim was processed.

Other payment information

View procedures not covered and the responsibilities of participating providers.

Provider audits

Audits determine medical necessity, utilization, coverage and appropriateness of services, and accuracy of claims submitted.

Electronic remittance advice (ERA)

We provide claims processing information to you electronically via American National Standards Institute (ANSI) 835 Electronic Remittance Advice (ERA).

You can use one of the options below to obtain your payment vouchers. Enrollment is quick and easy and there is no cost to you.

  • View vouchers online using Availity's Remittance Viewer.
  • Receive your vouchers electronically via an ANSI 835 ERA.
  • View your pended claims summary on the Availity Web Portal

Enrollment

Receive your payment vouchers electronically via an ANSI 835 transaction. Enrollment is quick and easy and there is no cost to you.

  • View vouchers online using Availity's remittance viewer.
  • Receive your payment vouchers electronically via an ANSI 835 ERA, using the Availity Provider Portal.

835 codes

We use Group Code "PI" (Payer Initiated Reductions) and do not use Group Code "OA" (Other Adjustment) except for the codes indicated on the Claim Adjustment Reason Codes list. View the list on the wpc-edi website. View the Explanation Code (EXCD) ANSI code crosswalk document.

Electronic funds transfer (EFT)

We require all provider claims to be submitted electronically and claim payments made via EFT. If you’re not already receiving payments via EFT, please register now.

To register for EFT

Receive fast, secure delivery of your claim's payments, use Availity's EFT Enrollment Tool.

The EFT Enrollment Tool is available on the main menu of the Availity Portal: My Providers>Enrollments Center>EFT Enrollment. You will be asked to identify your associated organization and payers.

Pharmacies:

  • Medical pharmacy claims and service: Sign-up for EFT using Availity's EFT Enrollment Tool
  • Pharmacy claims and services: Sign-up for EFT by contacting Prime Therapeutics at 1 (844) 765-6827

You will receive a confirmation email from Availity when your EFT registration is submitted and an email from us when your EFT set-up is complete. Upon completion, the next claim payment cycle will be sent electronically to your designated account.

EFT deposits will be made two business days after the payment issue date to comply with National Automated Clearing House Association (NACHA) guidelines. Note: We will make only credit entries to your designated bank account. If it becomes necessary to initiate a correcting debit, we will notify you in advance.

Updating your EFT information

If you change bank accounts, submit a change request using Availity's EFT Enrollment Tool.

Options for Receiving ERAs

  • View online using Availity's remittance viewer
  • American National Standards Institute (ANSI) 835 ERA, using the Availity Portal

Prompt payment regulations

We make every effort to pay or deny clean claims within thirty (30) days of receipt. A clean claim is a claim submitted on a properly completed paper or electronic claim form that does not require any additional documentation or information to determine our liability for payment. We determine what claims do not require substantiating documentation from the provider, information from a third party, or further review to determine our liability for payment.

Some types of claims are excluded from Prompt Pay laws, depending on individual state statutes and/or federal law. The following claims are commonly excluded:

  • Pharmacy
  • Medicaid entities
  • Capitated agreements
  • Claims paid to members
  • Asuris Pledge Medigap
  • Claims paid to members
  • Medicare Advantage Plans
  • Non-participating provider claims
  • Administrative services only (ASO) groups

The Washington State Prompt Pay statute is WAC 284-43-321. Additional information regarding timely payment is available in your agreement.