Claims submission

Claim attachments

Learn more about when, and how, to submit claim attachments.

Claims edits

If you do not submit your claims through Availity Essentials, follow this process to submit your claims to us electronically.

Coding toolkit

Learn more about our customized editing rules, including clinical edits, bundling edits, and outpatient code editor.

Modifiers

Learn more about informational, preventive services and functional modifiers.

Benefit coordination

Coordination of Benefits, Medicare crossover and other party liability or subrogation.

Medication claims

Learn how to submit claims for medications provided in your office.

Other billing information

Learn about billing for consultations, fragmented/split professional, dental and professional and other billing tips.

Claims submission

Our participating providers and facilities agree to bill us directly for covered services provided to our members in accordance with their participating agreement.

All providers that are eligible to contract with us must bill for all services they perform under their own name. A licensed provider may not submit claims for services performed by and on behalf of (i.e., incident to) another provider or Non-Physician Practitioner (NPP). Palliative care services are an exception to this.

We do not accept claims for, or provide coverage for, services rendered as part of a residency or fellowship program. Claims should not be submitted under the name and identifier of the attending or supervising provider.

Patient eligibility and benefits should be verified through Availity Essentials.

  • Patients may be asked for estimated copayment, deductible or coinsurance at the time of service.
  • After services are rendered, the patient should only be billed for any remaining deductible, copayment and/or coinsurance amounts not collected and non-covered services.

Centers for Medicare & Medicaid Services (CMS) provides regulations and guidance on correct billing and coding use.

ANSI v5010 transactions

Type

Description

Contact information

270/271

Eligibility Request and Response

Contact Availity

276/277

Claims Status Inquiry and Response

Contact Availity

277CA

Health Care Claim Status Acknowledgement

No enrollment needed, submitters will receive this transaction automatically

278

Web portal only: Referral request, referral inquiry and pre-authorization request

Contact Availity

835

Remittance Advice

Contact Availity

837

Health Care Claim

Contact Availity

999

Implementation Acknowledgement for Health Care Insurance

No enrollment needed, submitters will receive this transaction automatically

TA1

Interchange Acknowledgement

No enrollment needed, submitters will receive this transaction automatically