Business Run Out for Optima Health and Group Number VP
Claims Processing
- Claims runout periods will extend through the timely filing duration of the provider agreement. This will apply to both Optima Group: VP (Medicaid) and Virginia Premier DSNP (Medicare) claims.
- Paper claims can be submitted through the existing channels for run out.
- We will apply internal processes to re-route claims submitted to the incorrect location.
- Providers should use 54154 payer ID.
- Change Healthcare users only must use VAPRM for claims runout for Optima Group: VP.
The Claim Adjustment/Reconsideration Form
Span Billing for Outpatient Services
Outpatient providers will be required to bill span dates crossing over 1/1/24 separately, with service dates prior to 1/1/24 billed distinctly from those following 1/1/24. Except for interim billing, inpatient/facility claims will be adjudicated based on the admit date and will not require a separate bill.
Claims Submission Starting January 1st
Beginning on January 1, all providers can use the 54154 for both runout and future business for all current participating clearinghouses with one exception, Change Healthcare submitters only, should continue to utilize VAPRM for Group Number VP claims runout activity until further notified.
Electronic Submissions - We accept claims through any clearing house that can connect through Availity, Veradigm (Payerpath/Allscripts) or Change Healthcare.
Mail Paper Claims to:
Medical Claims: PO Box 8203, Kingston, NY 12402-8203
Behavioral Health Claims: PO Box 8204, Kingston, NY 12402-8204
Timely Filing
As a reminder Sentara Health Plans allows 365 days for initial timely filing from the service date for all claims.
For Medicaid, all PAR and non-PAR providers are given 365 days to file reconsideration claim. For non-PAR Medicare providers have 60 days from claim adjudication date to file reconsideration
and must also submit “Waiver of Liability” which states they will not balance bill patient regardless of reconsideration outcome. More information
Reconsiderations
Reconsiderations (sometimes confused with claims corrections) is a provider written notification to dispute the processed claim payment/denial.
Submit reconsiderations through the following methods:
1. Online Using Group Number VP Portal:
- All Group Number VP claims for DOS prior to 1/1/24
- Optima Health Medicare claims for DOS 5/1/23 forward
- All Sentara Health Plan Medicaid and Medicare claims for DOS 1/1/24 forward
2. Mail
- Medicaid and Medicare are optional
- Commercial reconsiderations must still be mailed until further notice
• Medical Claims: PO Box 8203, Kingston, NY 12402-8203
• Behavioral Health Claims: PO Box 8204, Kingston, NY 12402-8204
Corrected Claims Corrections on paper can be mailed to:
• Medical Claims: PO Box 8203, Kingston, NY 12402-8203
• Behavioral Health Claims: PO Box 8204, Kingston, NY 12402-8204
CMS 1500: Corrected claims submitted on a paper CMS 1500 form should include the original claim number and submission code 7 in field 22 to prevent misidentification of the corrected claim as a duplicate submission. Until further notice, corrected claims submitted on a CMS 1500 form can also be submitted electronically (without attachments) through Provider Connection.
UB04 The bill type should end in 7 with original claim number showing in field 80 to prevent misidentification as a duplicate submission.
Medical Providers may submit corrected claims online through Provider Connection by selecting Medical Claims, selecting the claim in question, and choosing the Correct Claim option. You may make corrections online to CPT code, diagnosis, billed charges, quantity and/or place of service.
Prior to submitting corrected claims electronically, please contact your clearinghouse to learn their requirements.
Consistent with Health Insurance Portability and Accountability Act (HIPAA) requirements, please submit corrected claims in their entirety following these guidelines:
Make the changes in your practice management system, so the corrections print on the amended claim. Please do not make handwritten corrections on the claim.
Send the entire corrected claim (even line items that were previously paid correctly). The corrected claim will be compared to the original claim and all charges for that date of service. Any partially corrected claim will be denied.
Provider and patient information must be included on the claim.
Physician claims: Enter 7 in electronic field 12A or box 22 of the paper CMS-1500 form.
Facility claims: UB Type of Bill should be used to identify the type of bill submitted as follows:
XX5 Late charges only
XX7 Replacement of previous bill (corrected claim)
XX8 Void/cancel previous claim
Appeals – Sentara Health Plans will continue the practice of accepting appeals submitted in writing within 365 days from the date of service for claims appeals. Clinical appeals must be submitted within 60 days of notice of denial, unless otherwise determined by their contract with the health plan. Detailed information and supporting written documentation should accompany the appeal. A decision will be rendered within 30 business days of receipt of the appeal request, with a 14-day extension if it is in the best interest of the member.
Mail to:
Sentara Health Plans Appeals and Grievances
PO Box 62876
Virginia Beach, VA 23466
Medicaid Provider Services: 800-881-2166
Medicaid Appeals and Grievances Phone: 844-434-2916
Medicaid Fax: 866-472-3920
Medicare Provider Services: 800-927-6048
Medicare Appeals and Grievances Phone: 855-813-0349
Medicare Fax: 800-289-4970
Remittance Advice
Beginning on January 1, 2024, all Sentara Health Plans Medicare and Medicaid products will be processed on a single remit and an active PaySpan Account will be required. The EFT enrollment process for commercial and self-funded products remains as follows until further notice:
1.Complete in its entirety the EFT/ERA Authorization Agreement PDF form
2.Obtain a letter from your bank on the bank’s letterhead, including the physical bank
address, account number, the bank employee’s name, title, email, and phone number.
Letter must not be dated more than 90 days prior.
3. The form must be signed by the provider or an authorized representative of the provider.
4. Submit all the documents by email to EFT_ERA_Inquiry@sentara.com
5. Optima Health will validate the provider’s relationship with the banking institution.
6. Tax ID information will be validated in the payment System.
7. Once the process is complete, the EFT information will be input into the payment system
and the Provider will be notified that the set-up has been completed.
Register for PaySpan
To start the PaySpan registration process, you may contact providersupport@payspan.com or call 1-877-331-7154, option 1 to obtain the registration codes and assistance with navigating the website. You will receive the requisite registration code and can also request assistance with navigating the website. PaySpan is available Monday – Friday, 8 a.m. – 8 p.m.
Learn more
Negative Balances
For Optima Group VP (formerly Virginia Premier) providers, beginning on January 1, recoupments will no longer appear on your EOPs as an advance. You will begin receiving a monthly negative balance statement around the first Friday of every month for claims that are being held to offset monies owed for claims that are unable to be retracted as well as refund request letters for the claims owed back to the health plan.
Note: Providers are required to register with PaySpan if they do not have an active account. Providers with active accounts that attempt to register again will receive the message "There is no registration code available." If this occurs, the provider must contact PaySpan directly at providersupport@payspan.com.