Claims and Billing

Submit claims through electronic data interchange (EDI) for faster, more efficient claims processing and payment. Select Health's EDI payer ID number is 23285.

Electronic claims may be submitted via:

Availity

• Providers or clearinghouses not currently using Availity to submit claims must register at Availity
• Providers who are currently registered with Availity for another payer, or using another clearinghouse, must request to have electronic claims for Select Health routed to Availity.
• For registration process assistance, submit the Provider Inquiry form at the bottom of the Availity webpage or contact Availity Client Services at 1-800-AVAILITY (282-4548). Assistance is available Monday through Friday from 8 a.m. to 8 p.m. ET.

Optum/Change Healthcare

• Providers who have a software vendor or use another clearinghouse to submit claims to Optum/Change Healthcare will need to consult with their vendor/clearinghouse to see if there have been changes in their process for claims submission.
• For questions, contact Optum/Change Healthcare’s call center at 1-800-527-8133, Monday through Friday from 7 a.m. to 5:30 p.m. CT.

Providers may submit manual/direct entry claims (at no cost) via:

Optum/Change Healthcare ConnectCenter™

• Access the portal via the Claims submission link in the NaviNet provider portal or via ConnectCenter to complete your provider registration.
  • Note: this URL is specific to new provider registration only.
• For detailed instructions on the registration process, see the Provider Sign-up and User Management guide in the Claim Resource section at the bottom of this page.
• Follow the instructions on the login page to reset your password and to set up the required multi-factor authentication.
• For more information on available functionality, please review the release notes in the Product News section after signing into the ConnectCenter portal.
• Optum/Change Healthcare also provides other helpful user guides to assist providers with navigating the ConnectCenter portal. These guides, are also available in the Claim Resource section at the bottom of this page.

PCH Global

To enroll for claims submission through PCH Global, please go to: pchhealth.global.

1. Click the Sign-Up link in the upper right-hand corner.
2. Complete the registration process and log into your account. You will be asked how you heard about PCH Global; select Payer, then AmeriHealth.
3. Access your profile by clicking on Manage User and then My Profile. You will need to complete all the profile information. When you go to the Subscription Details screen, select the More option on the right-hand side to see how to enter the promo code Exela-EDI.
4. When you are ready to submit claims, use the following information to search for our payer information:
   • Payer name: AmeriHealth-ACFC-South Carolina
   • P.O. Box: 7120, London, KY 40742

For a detailed walk-through of the registration process, refer to the PCH Global Registration manual (PDF), found on the PCH Global website in the Resource Menu.

Send paper claims to:

Select Health of South Carolina
Attn: Claim Processing Department
P.O. Box 7120
London, KY 40742

Select Health is accepting ANSI 5010 ASC X12 275 claim attachment transactions (unsolicited). Please contact your Practice Management System Vendor or EDI clearinghouse to inform them that you wish to initiate electronic 275 claim attachment transaction submissions for payer ID: 23285 via:

Availity

There are two ways 275 claim attachments can be submitted:

• Batch — You may either connect to Availity directly or submit via your EDI clearinghouse.
• Portal — Individual providers may also register at the Availity. Portal-Registration site to submit attachments.

After logging in, providers registered with Availity may access the Attachments - Training Demo for detailed instructions on the submission process or refer to the Availity Claims Attachment Quick Reference Guide (PDF).

Optum/Change Healthcare

There are two ways that 275 attachments can be submitted:

• Batch — You may either connect to Optum/Change Healthcare directly or submit via your EDI clearinghouse.
• API via JSON — You may submit an attachment for a single claim.

General guidelines

• A maximum of 10 attachments are allowed per submission. Each attachment cannot exceed 10 megabytes (MB) and total file size cannot exceed 100 MB.
• The acceptable supported formats are pdf, tif, tiff, jpeg, jpg, png, docx, rtf, doc, and txt.
• The 275 attachments must be submitted prior to the 837. After successfully submitting a 275 attachment, an Attachment Control Number will generate. The Attachment Control Number must be submitted in the 837 transactions as follows:
• CMS 1500
  • Field Number 19
  • Loop 2300
  • PWK segment
• UB-04
  • Field Number 80
  • Loop 2300
  • PWK01 segment

In addition to the attachment control number, the following 275 claim attachment transaction report codes must be used when submitting an attachment. Enter the applicable code in field number 19 of the CMS 1500 or field number 80 of the UB04, as documented in the Claims Filing Instructions (PDF).

To inquire about claim status, sign in to NaviNet and select Claims Status Summary under Administrative Reports. Provider Claim Services can also check the status of up to five claims via phone at 1-800-575-0418.

Requests for reconsideration may be submitted through the NaviNet Electronic Claim Inquiry feature. For detailed information on electronic claim inquiry submission, please see the NaviNet Claims Investigation User Guide (PDF).

A health care professional/provider dispute is an escalated verbal or written expression of dissatisfaction by a health care professional/provider, not otherwise acting in the capacity of an authorized representative of a Select Health member, to dispute the denial of payment of a claim or regarding a decision that directly impacts the health care professional/provider. In the case of a contracted, in-network health care professional/provider, the provider dispute system addresses the plan’s policies, procedures, or any aspect of the plan’s administrative functions. Providers not otherwise acting in the capacity of an authorized representative of a Medicaid managed care member do not have appeal rights. For a noncontracted out-of-network health care professional/provider, the provider dispute system addresses nonpayment, denial, or reduction of a covered service rendered out of network, including emergency care. Provider disputes are generally administrative in nature, involving post-service denials or reductions, as well as claims issues.

Disputes should be submitted within 60 calendar days from the original adverse determination. Disputes received after 60 calendar days from the original adverse determination are subject to denials due to untimely submission.

Provider disputes may be submitted via the Provider Claim Dispute Form (PDF).

An appeal is a request for review of an adverse benefit determination and are for preservice issues.  An adverse benefit determination could be the denial or limited authorization of a requested service, including the type or level of service or reduction, suspension, or termination of a previously authorized service.  Providers do not have the right to an appeal except on behalf of the affected member.

Note: A signed member consent form (PDF) is required to file an appeal on behalf of a member.

Examples of reasons to appeal include:

• The denial or limited authorization of a requested service, including the type or level of service.
• The reduction, suspension, or termination of a previously authorized service.

Appeals should be submitted within 60 calendar days from the original adverse determination. Appeals received after 60 calendar days from the original adverse determination are subject to denials due to untimely submission.

Appeals may be submitted:

• Verbally by calling the Appeals department at 1-866-615-5186.
  • Note: If the request is for an expedited resolution, an oral filing must be followed up with a written, signed appeal within 30 calendar days of the oral filing.
• Faxing 1-866-369-6046
• Mailing:
  • Select Health of South Carolina
    Attn: Member Appeals
    P.O. Box 40849
    Charleston, SC 29423-0849

If a plan provider identifies improper payment or overpayment of claims from Select Health, the improperly paid or overpaid funds must be returned to the plan within 60 days from the date of discovery of the overpayment. Please include the member’s name and ID, date of service, and claim ID.

Providers are required to return the improper or overpaid funds by:

• Completing page one of the Provider Refund Claim Form (PDF).
• Using page two of the form, as needed, to list multiple claims connected to the return payment.
• Submitting the completed form and refund check by mail to the Claims Repayment Research Unit:
  • Select Health of South Carolina
    Attn: Claims Repayment Research Unit
    P.O. 7120
    London, KY 40742

If the plan provider would prefer the improper payment or overpayment be recouped from suture claims payment, the provider should call the Provider Claims Service Center or send the completed Provider Refund Claim Form (PDF) without a refund check to the address below:

• Cost Containment Department
  P.O. Box 7320
  London, KY 40742

Select Health offers ERAs through ECHO Health, Inc. ECHO is a leading provider of electronic solutions for payments to health care providers. ECHO consolidates individual provider and vendor payments into a single compliant format, remits electronic payments, and provides an explanation of payment (EOP) details to providers.

To receive ERAs, providers will need to include both the plan payer ID and the ECHO payer ID 58379. Contact your practice management/hospital information system for instructions on how to receive ERAs from Select Health under payer ID 23285 and the ECHO payer ID 58379.

All ECHO Health-generated ERAs and EOPs for each transaction will be accessible to download from the ECHO provider portal. If you are a first-time user and need to create a new account, please reference ECHO Health's Provider Payment Portal Quick Reference Guide (PDF) for instructions.

If your practice management/hospital information system is already set up and can accept ERAs from Select Health, it is important to check that their system includes both the plan and ECHO Health payer IDs.

If you are not receiving any payer ERAs, contact your current practice management/hospital information system vendor to ask if your software can process ERAs. Your software vendor is then responsible for contacting Optum/Change Healthcare to enroll for ERAs under 23285 and ECHO Health payer ID 58379.

If your software does not support ERAs or you continue to reconcile manually, but would like to start receiving ERAs only, please contact the ECHO Health Enrollment team at 1-888-834-3511.