CurrentAmeriHealth Caritas VIP CarePolicy RPC.0016.FLDS

Submission of Claims

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Guidance for providers submitting and processing health care claims billed on CMS-1500 or UB-04 forms, or electronic equivalents, including requirements for clean claims, coding, documentation, eligibility, filing deadlines, corrections, and related billing topics.

Policy Summary

PayerAmeriHealth Caritas VIP Care

PolicySubmission of Claims

Policy CodePolicy RPC.0016.FLDS

Change TypeAdministrative and non-material revision

Effective DateN/A

Last ReviewJun 1, 2026

Next Review DateJul 1, 2028

Key ActionVerify member eligibility, coverage dates, benefit limitations, and authorization requirements before rendering services.

SourceLink

POLICY UPDATE CHANGES

The policy added associated policies for durable medical equipment, obstetrics, home health services, and corrected claims.

The policy added a definition and additional language for clean claims.

The reimbursement guidelines were expanded to address claim submission, coding, documentation, eligibility, corrected claims, and service-specific billing topics.

90 days–1 yearTypical claim filing deadline

5 daysHome health admission deadline

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CurrentAmeriHealth Caritas VIP CarePolicy RPC.0016.FLDS

Submission of Claims

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Policy Summary

PayerAmeriHealth Caritas VIP Care

PolicySubmission of Claims

Policy CodePolicy RPC.0016.FLDS

Change TypeAdministrative and non-material revision

Effective DateN/A

Last ReviewJun 1, 2026

Next Review DateJul 1, 2028

Key ActionVerify member eligibility, coverage dates, benefit limitations, and authorization requirements before rendering services.

SourceLink

POLICY UPDATE CHANGES

The policy added associated policies for durable medical equipment, obstetrics, home health services, and corrected claims.

The policy added a definition and additional language for clean claims.

The reimbursement guidelines were expanded to address claim submission, coding, documentation, eligibility, corrected claims, and service-specific billing topics.

90 days–1 yearTypical claim filing deadline

5 daysHome health admission deadline

Home health claim deadline

QuarterlyNCCI edit updates

General Claim Processing Requirements

General Claim Submission Requirements

Claims must satisfy all applicable submission, coding, documentation, eligibility, and contractual requirements for processing and potential reimbursement.

ALL of the following

ALL of the following
- Submit claims on a CMS-1500 or UB-04 form, or an electronic equivalent, as applicable.
- Provide accurate patient and provider information, service details, diagnosis and procedure codes, and all required supporting documentation.
- Submit claims within the applicable timely filing deadline; claims received beyond the limit will not be reimbursed.
- Verify member eligibility, coverage dates, benefit limitations, and authorization requirements before rendering services.
- Ensure claims are legible and complete; illegible fields may result in rejection or denial.
The inclusion of a procedure or diagnosis code does not imply that the service is covered or guarantee reimbursement.
Coverage and payment remain subject to applicable federal, state, contractual, eligibility, documentation, and other health plan requirements.

Corrected Claims and Adjustments

Corrected claims must follow the original-claim processing and notification requirements.

ALL of the following

Wait until all charges are documented before filing the initial claim.
Adhere to timely filing deadlines for initial and corrected submissions.
Submit a corrected claim only after the original claim has been processed and a status notification has been received.
ALL of the following
- When submitting a claim with bill type xx7, ensure the condition code clearly specifies the nature of the requested change or adjustment.

Coding and Filing Requirements

Diagnosis and procedure codingmixed

ICD-10-CM	Specific and current diagnosis codes that support the services performed
CPT	Procedure codes describing and supporting the services performed

NCCI code compliancemixed

HCPCS	Procedure and supply codes used for claims and NCCI compliance
CPT	Procedure codes subject to applicable NCCI edits

Condition codes for claim changes or adjustmentsmixed

D0	Change in Service Dates
D1	Change in Charges
D2	Change in Revenue Codes
D3	Change in Diagnosis
D4	Change in Procedure Codes
D7	Change in Patient Status
D8	Change in Diagnosis and Procedure Codes
E0	Change in Patient Status and Diagnosis

Typical timely filing limit

Typical filing range90 days to 1 year

Late submissionsClaims received beyond the timely filing limit will not be reimbursed.

VerificationVerify the specific filing limit in the AmeriHealth Caritas VIP Care provider manual.

Home health Notice of Admission deadline

Submission deadlineWithin 5 days of the start of care

Required submissionNotice of Admission (NOA)

Provider Submission Checklist

Documentation Required

Required Claim Elements

Include complete and accurate claim information to support processing and reimbursement. Claims should identify the patient and provider, describe the services rendered, use the appropriate diagnosis and procedure codes, and include all required supporting documentation.

Accurate patient and provider demographics and identifiers
Dates and details of services rendered
Specific and current ICD-10-CM diagnosis codes paired with appropriate CPT or HCPCS codes
Required records, insurance information, authorization numbers, and other supporting documentation

Billing Rule

Submit Electronic Claims Through Compliant Systems

Claims Terminology

Clean claim

DefinitionA request for payment with no defects, improprieties, or missing information requiring outside investigation or development.

Automated editsPasses all automated system edits.

Adjudication statusCan be adjudicated immediately.

Policy Summary

PayerAmeriHealth Caritas VIP Care

PolicySubmission of Claims

Policy CodePolicy RPC.0016.FLDS

Change TypeAdministrative and non-material revision

Effective DateN/A

Last ReviewJun 1, 2026

Next Review DateJul 1, 2028

Key ActionVerify member eligibility, coverage dates, benefit limitations, and authorization requirements before rendering services.

SourceLink

On This Page

Claims submitted with bill type xx7 may be denied when the condition code does not clearly specify the nature of the requested change or adjustment.

Follow-up requirement

The NOA is followed by a claim submission.

Home health claim deadline

Submission deadlineWithin 1 year of service

Applies toHome health claims

Submission sequenceSubmit the claim after the Notice of Admission, which is due within five days of the start of care.

Submit electronic claims through a compliant electronic filing system. AmeriHealth Caritas VIP Care prefers EDI submission, and the system must meet HIPAA claim-standard requirements and applicable CMS requirements, including provider enrollment and EDI enrollment requirements.

Use a HIPAA-compliant electronic filing system
Meet applicable CMS electronic filing, provider enrollment, and certification requirements
Ensure all electronic claim fields are legible and complete

Billing Rule

Apply NCCI Coding Edits

Use the appropriate HCPCS and CPT codes and apply the National Correct Coding Initiative (NCCI) edits when preparing claims. Follow the CMS Procedure-to-Procedure (PTP) and Medically Unlikely Edit (MUE) files, which are updated quarterly.

Use codes that accurately describe and support the services performed
Review the current CMS NCCI PTP edit files
Review the current CMS NCCI MUE edit files

Documentation Required

Provide DME Supporting Documentation

For durable medical equipment (DME) claims, submit the required order and documentation demonstrating that the equipment is medically necessary. Use the appropriate CMS-1500 form or electronic equivalent and meet the payer’s specified filing deadline.

Physician’s Standard Written Order (SWO) or Written Order for Prior Approval (WOPD)
Medical records supporting medical necessity
Proof of Delivery (POD)

Billing Rule

Meet Home Health Submission Requirements

For home health services, submit a Notice of Admission (NOA) within five days of the start of care, followed by the claim within one year of the date of service.

Submit the NOA within 5 days of the start of care
Submit the subsequent claim within 1 year of service

Denial Risk

Verify Eligibility Before Rendering Services

Verify member eligibility before rendering services to confirm that coverage applies. Failure to verify eligibility may result in claim denial.

Confirm active coverage and applicable coverage dates
Review benefit limitations
Confirm whether prior authorization or other authorization requirements apply