Virginia Premier Health Plan, Inc.

Claims FAQs

Q: Can I check my claim status online?
We are currently working to bring you this capability.  Providers will be notified when information is accessible online.

Q: Can I use a copy of a form or one that has been printed in black ink?
No. Per the National Uniform Claim Committee (NUCC):
“In order for the form to be read by a scanner, the form must be in red ink. The red ink that is specified for the form allows scanners to drop the form template during the imaging of the paper. This "cleaner" image is easier and faster to process with data capture automation such as ICR/OCR (Intelligent Character Recognition/Optical Character Recognition) software. Your vendor may choose not to process claim forms that are submitted in black ink.”

Q: Can I fill out my claim form by hand?
No.  All claims submitted must be computer generated or typed to ensure accurate processing.  All required fields and appropriate procedure/diagnosis codes must be accurate on the claim form in order to be considered a clean claim.

            Note:  Handwritten claims are subject to be denied or returned.

Q: What is considered a “clean claim”?
A “clean claim” is defined as a claim that has no material defect or impropriety (including any lack of any reasonably required substantiation documentation) which substantially prevents timely payment from being made on the claim or with respect to which Virginia Premier has failed to timely notify the person submitting the claim of any such defect or impropriety.

Q: Is the National Provider Identifier (NPI) Number required on all claims?
If you are a provider type where a NPI number is required, failure to include your NPI number on the claim could result in the claim being denied or rejected.  If you are a provider type where NPI is not required, contact our Claims department for information on receiving an Atypical Provider Identification (API).

Q: Is the place of service required?
Yes. All claims billed on a CMS form regardless of the provider type must have a valid place of service. Failure to enter the place of service could result in the claim being denied or rejected.

Q: How do I show the correct number of units when billing for rented durable medical equipment?
The number of units should always equal the actual number of days the equipment is rented. For example, when spanning dates of service such as, 1/1/09 – 1/31/09, the number of units should be “30”. Please refer to the DMAS Appendix “B” for more information on billing units.         

Q: Do you accept electronic claims?
Yes. For more information, see the Electronic Claims Submission page.

Q: How do I file an appeal?
All denied claims must be appealed in writing to Virginia Premier within sixty (60) days of the original date of denial.  The “appeal claim” must include any supporting documentation, which explains or satisfies the reason for the original denial and why it should be paid accordingly.

Non-medical denials (e.g. timely filing, duplicate claim, cannot ID member, triage payment etc.) should be appealed to:
            Virginia Premier Health Plan, Inc.
            Attention Appeals Department
            P. O. Box 5286
            Richmond, Virginia 23220-0286

Claims denied for medical reasons (e.g. not medically necessary, etc.) must be appealed to VPHP’s Medical Management Department with medical record documentation at:
            Virginia Premier Health Plan, Inc.
            Attention Medical Management Department
            P. O. Box 5244
            Richmond, Virginia 23220-0244
       
Some claim denials do not require an appeal and can be resolved by correcting the issue and simply refilling the claim.  Examples include:
•    Not Authorized: Re-file with the correct authorization number.
•    Invalid or Expired CPT Code: Correct the code(s) and re-file.
•    Invalid or Expired Diagnosis Code: Correct the code(s) and re-file.

The Appeal Claims form can be accessed in our Forms section.

Q:  If I make any contractual changes to my practice or business, what information do I need to provide to Virginia Premier Health Plan, Inc.’s Finance Department?
If you change your tax identification number, address, NPI #, legal business name or any other contractual changes please forward a W-9 along with your changes to your Contracting Representative immediately.  Doing this can avoid possible IRS regulated fines and/or withholdings from your claim, capitation and/or management fee payments.  In addition, any changes made without a W-9 attached will delay payment of any of your claims.

Q:  Where are the even pages to my Remittance Advice?
Remittance Advices (RAs) are printed on the front and back of each page.  Be sure if you scan remits, you capture both sides of the page.

Q:  How can I get a copy of an old Remittance?
For those Remittance Advices that are less than 60 days old, please call us to obtain a copy of your Remittance.  For those Remittances that are older than 60 days, we can create, upon request, a custom report with the data you need.  Please call the claims department at (804)819-5151 for help with this.

Q:  Can I get a copy of a cancelled check within the same month that it was printed?
A copy of a cancelled check cannot be provided for checks printed within the month of the request.  Please allow up to 14 days after the month end for such requests.  

Q:  When can I expect my fee for service payment?
Payments are usually processed every Friday and are mailed out by the following Wednesday of each week.  Deviations from the Friday pay date are usually due to holidays.  Please check with the Claims department to ensure whether or not the claims you are seeking payment for has been processed for payment.  You can contact the Claims department at either (804) 819-5151 or (800) 727-7536.  If you receive your payments via electronic funds transfer, you should receive your payment within 2 business days from Friday.  Check with your banking institution as all payments are paid from our account on Friday.  

Q:  I need a copy of a previous months Capitation, Management Fee or Administrative Fee Detailed Report.  Can I get a copy of that sent to me?
Unfortunately, due to ever changing enrollment data we may not be able to retrieve this information prior to 07/01/07.

Q:  I only know my member’s information, what department do I contact to receive payment information?
You can contact the Claims department at either (804) 819-5151 or (800) 727-7536.

Q:  I would like to get my money directly deposited into my bank account, is that possible?
Virginia Premier Health Plan, Inc. offers Electronic Funds Transfer (EFT) to contracted providers.  To sign up for this please complete the Electronic Funds Transfer Authorization Form.  Only providers with valid email accounts will be able to participate in the EFT program.

Q: I already have EFT set up but I need to make changes to my bank account, what do I do?
To change bank account information complete the EFT Change form found on our website and send it as instructed on the form.

Q:  I would like to have my Remittance Advice sent to me electronically, is that possible?
Virginia Premier Health Plan, Inc. does offer Electronic Data Interchange (EDI) for our Remittance Advices.  To participate in the program please complete the Electronic Remit (EDI 835) form.  For more information on this form and the program please contact the Claims Department at either (804) 819-5151 or (800) 727-7536.

Q:  Why do all changes need a W-9?
The IRS requires us to submit accurate information to them each year end.  Thus to make sure that we always have current information it is our policy to always request a W-9 for IRS compliance.

Q:  I do not have a W-9 already completed.  Where can I find one?
You can find a current blank W-9 on the IRS’s website.