The Claims Department at Virginia Premier is committed to providing you with the highest level of service possible. Our mission is to pay claims correctly and quickly the first time. Doing it right the first time saves time and money for everyone. We want to help you improve the premier health outcomes of our members by reducing the time you spend on claims follow-up.

If you have questions for the Claims Department or suggestions on how we can improve our operations, please call us at 800-727-7536, press 4 for Claims. Our fax number is 804-819-5174.

Forms

All of our forms can be found in our Provider Forms library.

Virginia Premier Health Plan (Medallion 3.0) Providers

Below is a list of Virginia Premier claim filing addresses:

  • PCP Claims
    PO Box 5207
    Richmond, VA 23220-0207
  • Specialty Claims
    PO Box 5208
    Richmond, VA 23220-0208
  • Hospital Claims
    PO Box 5120
    Richmond, VA 23220-0120
  • Transportation Claims
    PO Box 5287
    Richmond, VA 23220-0287
  • Claim Appeals
    PO Box 5286
    Richmond, VA 23220-0286

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.

Is the CLIA (Clinical Laboratory Improvement Amendments) certification number required on CMS 1500?

As of 6/15/13, Virginia Premier requires all providers performing lab services to submit a CLIA certificate number on both electronic and paper claims. The CLIA Certificate number should be populated in box 19 of the CMS 1500 form or in Loop 23 Segment REF X4 for electronic claims. Submitting a CLIA number is a federal requirement and failure to provide the require information will result in the denial of a claim and payment.

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.

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.

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) number.

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.

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, 11/1/13 – 11/30/13, the number of units should be “30”.
  • Please refer to the DMAS Appendix “B” for more information on billing units.

Do you accept electronic claims?

  • Yes. For more information, see the Electronic Claims Submission page.

How do I file an appeal?

  • All denied claims must be appealed in writing to Virginia Premier Health Plan, Inc. 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 Virginia Premier Health Plan, Inc. 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 the claim with the correct authorization number
  • Invalid or Expired CPT Code: Correct the code(s) and re-file the claim
  • Invalid or Expired Diagnosis Code: Correct the code(s) and re-file the claim
  • The Appeal Claims form can be accessed in the Claims section of the Provider Forms Library

If I make any contractual changes to my practice or business, what information do I need to provide to Virginia Premier’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.

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.

How can I get a copy of an old Remittance?

  • If your Remittance Advice is less than 60 days old, please call us to obtain a copy of your Remittance.
  • For Remittances older than 60 days, we can create, upon request, a custom report with the data you need. Please call the Claims Department at 800-727-7536, option 4 for assistance.

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 14 days after the month end for such requests.

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.
  • Delays from the Friday pay date are usually due to holidays.
  • Please check with the Claims department to ensure the claim you are seeking payment for has been processed for payment. You can contact the Claims department at 800-727-7536, option 4.
  • 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.

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?

  • You can contact the Claims department at either 800-727-7536, option 4.
  • Unfortunately, due to ever changing enrollment data we may not be able to retrieve this information prior to 07/01/2007.

I only know my member’s information, what department do I contact to receive payment information?

  • You can contact the Claims department at 800-727-7536, option 4.

I would like to get my money directly deposited into my bank account, is that possible?

  • Virginia Premier offers Electronic Funds Transfer (EFT) to contracted providers.
  • To sign up for this please complete the Electronic Funds Transfer Authorization Form, located in the Claims section of the Provider Forms Library.
  • Only providers with valid email accounts will be able to participate in the EFT program.

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, located in the Claims section of the Provider Forms Library, and send it in as instructed.

I would like to have my Remittance Advice sent to me electronically, is that possible?

  • Virginia Premier offers Electronic Data Interchange (EDI) for our Remittance Advices.
  • To enroll, please complete the Electronic Remit (EDI 835) form, located in the Claims section of the Provider Forms Library.
  • For more information on this form and the program please contact the Claims Department at 800-727-7536, option 4.

Why do all changes need a W-9?

  • The IRS requires us to submit accurate information to them each year.
  • Any changes to your provider information requires a current W-9 for IRS compliance.

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 website.
Clearinghouse Phone Website 837 Claims Professional 837 Claims Institutional 835 ERA






Availity (800) 282-4548 www.Availity.com YES YES YES
Benchmark (800) 779-0902 www.benchmark-systems.com YES NO NO
ClaimLogic (866) 252-4656 www.claimlogic.com YES NO YES
Emdeon (866) 742-4355 http://clientsupport.emdeon.com YES YES YES
Gateway EDI (Trizetto) (800) 556-2231 http://www.gatewayedi.com YES NO YES
MedAssets (866) 323-6332 http://www.medassets.com YES YES YES
eMedix (Notewrothy Medical Systems) (877) 891-8777 http://www.notworthyms.com YES NO YES
Allscripts / PayerPath (877) 623-5706 http://www.payerpath.com YES YES YES
RelayHealth (800) 527-8133 http://www.mckesson.com YES YES YES
The SSI Group (800) 880-3032 http://www.thessigroup.com YES YES YES
ZirMed (877) 494-7633 http://www.zirmed.com YES NO YES

If you have questions for the Claims Department or suggestions on how we can improve our operations, please call us at 800-727-7536, press 4 for Claims. Our fax number is 804-819-5174.

Virginia Premier CompleteCare (Medicare-Medicaid Plan) Providers

Below is a list of resources to help with submitting claims:

API Claims Submissions: CompleteCare– We want to make the process as easy as possible.  Learn about the portal and who to contact to get started here.

Clearinghouses: CompleteCare– Virginia Premier is pleased to be partnering with two of the largest clearinghouses in the industry to provide a full range of electronic capabilities for our CompleteCare providers and network partners.

CompleteCare Companion Guide– Instructions related to 837 Health Care Institutional & Professional Claims Transaction Based on ASC X12 Implementation Guides

Virginia Premier Health Plan (Medallion 3.0) Providers

Below is a list of Virginia Premier claim filing addresses:

  • PCP Claims
    PO Box 5207
    Richmond, VA 23220-0207
  • Specialty Claims
    PO Box 5208
    Richmond, VA 23220-0208
  • Hospital Claims
    PO Box 5120
    Richmond, VA 23220-0120
  • Transportation Claims
    PO Box 5287
    Richmond, VA 23220-0287
  • Claim Appeals
    PO Box 5286
    Richmond, VA 23220-0286

EDI (Electronic) Claims Submission

Virginia Premier strongly encourages our providers to file their claims electronically. By filing claims electronically, you are able to aid in lowering claims processing timeframes, which in turn allows Virginia Premier to make payments more quickly.

EDI 837 Claims

Please refer to the first document below for instructions on how to send EDI 837 (electronic) claims to Virginia Premier Health Plan, Inc. You will find answers to most of your questions here. The EDI 837 (Electronic Claims Enrollment) form can be found in the Claims section of the Provider Forms Library.

EDI 835 ERA

Should you want to receive the EDI 835 ERA (Electronic Remittance Advice) from Virginia Premier, the process is exactly the same as the process to send electronic claims to Virginia Premier. Only the form is different. The EDI 835 (Electronic Remittance Advice) form can be found in the Claims section of the Provider Forms Library.

Other EDI Transactions

Virginia Premier also offers additional transactions in partnership with our clearinghouses. If interested in either of the following, please contact your clearinghouse.
  • 277 – Claim Acknowledgment
  • 997 – Functional Acknowledgment

E-Mail: vphp_edi@vapremier.com

Technical Support: edi_support@vapremier.com

All of our forms can be found in the Claims section of the Provider Forms Library.