California PHP

To better serve our PHP Providers, PHP has contracted with Change Healthcare & Office Ally clearinghouses for the submission of all Electronic Data Interchange (EDI) claims. Initial claim(s) should be submitted electronically to PHP.  For claim(s) submission timeframe for contracted providers, please refer to your agreement with the plan, typically timely filing is 90 days from the date of service. The non-contracted providers claim(s) submission the timeframe is 365 days from the date of service. 

Change Healthcare & Office Ally Benefits and Advantages to EDI

• Reduce administrative burden – Reduce administrative fees related to the submission of claims and claims status transactions.
• Ability to submit 24/7 – PHP accepts all claims electronically, including professional and institutional related submissions 24 hours a day, seven days a week.
• Reduction of data entry and payment errors – Claims submitted electronically benefit from earlier detection of billing errors.  If your claim fails due to any pre-pass edit, the claim is returned back to your office for correction.  This editing reduces the likelihood of your claim being rejected or denied for payment once it enters the processing system. 
• Immediate verification of claims received – Receive immediate acknowledgement of claims received and confirmation through your clearinghouse within two days as to if claims have been accepted or rejected. 

What you Need to Know 

• Provider Bulletin – Electronic Claims Submission Update – Office Ally 10.01.2024
• Provider Bulletin – Electronic Claims Submission – Optum iEDI 03.18.2024
• PHP Payer Id: 95411  

Clean Claims Billing Requirements

Before PHP can process your claim, it must include all required information, where applicable and be “clean” of any errors. Please use the below document as a guide to identify the requirements for a clean claim submission.

Claim(s) that do not meet “clean” claim criteria will be rejected and denied back to the provider for correction.

Providers sending professional and supplier claims to PHP on paper must use Form CMS 1500 in the latest valid version. This form is maintained by the National Uniform Claim Committee (NUCC), an industry organization in which CMS participates.

Resources

Clean Claim Billing Requirements CMS 1500  
Clean Claim Billing Requirements UB 04 

Unable to Submit through a clearing house?

Office Ally provides a portal to submit “paper” claims if you do not have a clearing house. When submitting to AHF there is no cost to you! Use the link below and click the “Start Now” to sign up and begin submitting claims.

https://cms.officeally.com/

https://cms.officeally.com/payerlist/

PHP shall identify and acknowledge the receipt of each claim, whether or not complete, and disclose the recorded date of receipt to the billing practitioner as follows: 

• • EDI Claim, within 2 working days of the date of receipt of the claim. 
  • Paper Claim, within 15 working days of postmarked envelope. 

The “Received Date” is the oldest PHP date stamp on the claim. Acceptable date stamps include any of the following: 

• • PHP’s Claims department date stamp 
  • Primary payer claim payment/denial date 

Balance billing is when a practitioner charges beneficiary for Medi-Cal and/or Medicare covered services. Balance billing PHP Members is prohibited by law. 

Contracted providers cannot collect reimbursement from a PHP Member or persons acting on behalf of a Member for any services provided, except to collect any authorized share of cost co-insurance, co-payment or deductibles when applicable.

Providers participating in Medi-Cal and/or Medicare are prohibited from balance billing any PHP Member eligible for Medi-Cal and/or Medicare. Network providers who engage in balance billing are in breach of their contract with PHP. 

Providers who engage in balance billing may be subject to sanctions by PHP, CMS, DHCS and other industry regulators. 

For contracted providers, PHP cannot impose a timeframe for receipt of the first “initial claim” submission that is less than 90 days after the date of service for timely filing for a new claim. PHP may deny a claim that is submitted beyond the claim filing deadline. Non-contracted providers have 365 days from the Date of Service to submit.

An incomplete claim is defined as any claim with incomplete, missing or invalid information. Incomplete claims are considered non-clean and may be rejected or denied back to the provider for correction and resubmission of a clean claim.  

PHP requires a current W-9 form to be on file in order to process any claims. The W-9 form will be used to verify your mailing/remittance address. Claims received from Providers that do not a W-9 form on file will be administratively denied as non-clean. Providers are expected to respond to the Plan’s request for a valid W-9 form for payment. 

There are two ways Providers can submit their W-9 form to PHP: 

• Email to PDM Department [email protected] 
• Fax W-9 Form (without paper claim) to: 888-971-4418 

All payments, checks, claims remittance advices and 1099s will be mailed to the address listed on the W-9, as applicable. 

Please note that an updated W-9 is required but not limited to the following changes: 

• Mailing Address, 
• Legal Business Name, 
• Ownership 
• TAX ID Number 
• IRS form publication update 

Member Verification and Claims Status Portal 

The Member Verification and Claims Status Portal is the preferred method for contracted providers to check claims status. This portal allows you to: 

• View member eligibility 
• Lookup claims status 
• View important plan materials & information (Provider Manuals, Member SOB, etc…)

ECHO – Provider Payments Portal 

PHC California has partnered with Change Healthcare and ECHO Health, Inc to provide payments to providers. Providers can register on the ECHO provider portal (http://www.providerpayments.com).  

Payment Delivery Options include: 

• • Virtual Credit Card- Default payment method for all providers 
  • Electronic Fund Transfer (EFT) 
  • Medical Payment Exchange (MPX) 
  • Paper Check 

To manage or change your Payment Delivery Option, you must opt out of Virtual Card Services by visiting https://echovcards.com/letter and select another payment delivery option.  

Learn more about our Provider Portals.

Physician Fee Schedule

PHP is a Medicare managed care plan and follows the Medicare fee schedule, unless a differing reimbursement rate is contracted. (By clicking on the link above, you will go to the Medicare website which is operated by the Centers for Medicare and Medicaid Services (CMS) and not PHP.)

Standard Code Sets

Standard Code Sets as required by HIPAA are the codes used to identify specific diagnosis and clinical procedures on claims and encounter forms. All providers are required to submit claims and encounters using current HIPAA compliant codes, which include the standard CMS codes for ICD10, CPT, HCPCS, NDC and CDT, as appropriate.

A provider has a right to file a dispute in writing to PHP within 365 day from the date of service or the most recent action date, if there are multiple actions. PHP makes available to all providers a fast, fair and cost-effective dispute resolution mechanism for disputes regarding invoices, billing determinations or other contract, non-contracted issues. The dispute resolution mechanism is handled in accordance with applicable law and your agreement. A provider dispute is a written notice to PHP challenging, appealing or requesting reconsideration of a claim. The following are examples of disputes: 

• Claims payment disputes: challenging, appealing or requesting reconsideration of a claim (or bundled group of claims) 
• Benefit determination disputes: seeking resolution of a benefit determination 
• Payment of a claim 
• Denial of a claim 
• Timely filing denial 
• Seeking resolution of a billing determination
• Seeking resolution of another contract dispute 
• Disputing a request for reimbursement of an overpayment to a claim 

Providers may submit disputes on a Provider Claims Dispute Submission Form.

Each provider claim dispute must contain the following information at a minimum:

• Provider’s name
• Provider’s identification number
• Provider’s contact information
• If the provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from PHP to a provider, the request must include:
  
  • A clear identification of the disputed item
  • The date of service
  • A clear explanation of the basis upon which the provider believes the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment or other action is incorrect.

PHP issues a written determination regarding a provider claim dispute within 60 calendar days after receipt of the dispute. For those provider claim disputes that require amending by the provider, the plan issues a written determination within 60 calendar days after receipt of an amended dispute.

To obtain a national provider identifier (NPI) you may:

• Telephone: (800) 465-3203 or TTY: (800) 692-2326
• E-mail [email protected]
• Mail to NPI Enumerator P.O. Box 6059 Fargo, ND 58108-6059
• Refer to CMS’s NPI information (By clicking this link, you will be taken to the Centers for Medicare and Medicaid Services’ website.)