Billing Reference Sheets and Claims Submission and Guidelines
Find information on Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Coding and a quick reference guide for common Long Term Services & Support (LTSS) related to billing issues.
Coverage Decisions and Appeals
Various documents and information associated with coverage decisions and appeals.
Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Authorization Agreement Instructions
Instructions on how to complete the EFT / ERA agreement and setup.
Non-Participating Provider Registration Form
Non-Participating Providers can use this form to register or update their information.
Requests for Remittance Advice
Advice for participating providers who have EFT setup.
Provider Reconsideration Form
Use this form to request Reconsideration of a Denied Pre-authorization.
Ending Surprise Medical Bills From Out-of-Network Providers
The Consolidated Appropriations Act of 2021 established several new requirements to protect consumers from surprise medical bills from out of network providers and facilities. These requirements are collectively referred to as “No Surprises” rules. The Commonwealth of Virginia has also established similar regulations for health plans issued in Virginia. These requirements generally apply to covered items and services furnished by out of network non-plan providers to consumers enrolled in group health plans, group or individual health insurance coverage, and Federal Employees Health Benefits plans. These provisions do not apply to services provided to consumers enrolled in Medicare or Medicaid, or Tricare plans.
New Surprise Billing Requirements and Prohibitions include:
- No balance billing for out-of-network emergency services
- No balance billing for non-emergency services by out-of-network providers during patient visits to certain in-network health care facilities, unless notice and consent requirements are met for certain items and services.
- No balance billing for covered air ambulance services by out-of-network air ambulance providers
- In instances where balance billing is prohibited, cost sharing for insured patients is limited to in-network levels or amounts
Payors are required to make an initial payment for the services described above directly to the out of network provider within 30 days of receipt of a clean claim. CMS and Virginia regulations provide the following actions to resolve payment disputes:
- An open negotiation period must be initiated in writing within 30 days, beginning on the day the OON provider receives either an initial payment or a notice of denial of payment for the item or service from the plan or issuer.
- Parties must exhaust a 30 day open negotiation period before either party may initiate the Federal IDR Process.
- Either party may initiate the Federal IDR Process by submitting a written Notice of IDR Initiation to the other party and to the Departments within 4 business days after the close of the open negotiation period.
CMS and Virginia dispute processes have strict requirements and timeframes for each step.
Providers, facilities, or their representatives must follow the instructions and use the specific contact information provider on paper or electronic remittance documents (“explanation of payment EOPs”) to initiate negotiation or IDR.
For questions, please contact provider services at 1-800-229-8822.