Receiving payment

Professional reimbursement

Learn about our professional reimbursement methodology.

Overpayment recovery

Payments are occasionally recouped due to a duplicate or adjusted claim. View instructions for responding to a recoupment request.

Pricing disputes and appeals

Pricing disputes are not appeals and follow a different process. Identify the correct process to follow when submitting a pricing dispute or appeal.

Grace periods

Learn how submitted claims may be impacted by the three month grace period for premium payment for patients on an exchange product.

Procedures not covered

View conditions or procedures that are typically excluded under our contracts.

Provider audits

Audits determine medical necessity, utilization, coverage and appropriateness of services, and accuracy of claims submitted.

Receiving payment

Receiving prompt payment is essential to your office. Learn how to make this process more efficient.

ANSI 835 Electronic remittance advice

We provide claims processing information in an ANSI 835 Electronic Remittance Advice (835 ERA) format.

You can use the options below to obtain your claims payment information. Enrollment is quick and easy and there is no cost to you.

  • View claims payment information online in human-readable format using Availity's Remittance Viewer.
  • Receive your remittance advice electronically via an ANSI 835 ERA. Enrollment is quick and easy and there is no cost to you.

835 codes

We use Group Code "PI" (Payer Initiated Reductions) and do not use Group Code "OA" (Other Adjustment) except for the codes indicated on the Claim Adjustment Reason Codes list. View the list on the wpc-edi website. View the Explanation Code (EXCD) ANSI code crosswalk document.

Electronic funds transfer (EFT)

Claim payments via EFT is a requirement for participation in our networks. In addition, we require all provider claims to be submitted electronically. If you’re not already receiving payments via EFT, please register now.

To register for EFT

Receive fast, secure delivery of your claim's payments, use Availity's Transaction Enrollment Tool.

The Transaction Enrollment Tool is available on the main menu of Availity Esentials: My Providers>Enrollments Center> Transaction Enrollment. You can view a dashboard with updates and the status of your EFTs.

Pharmacies:

  • Medical pharmacy claims and service: Sign-up for EFT using Availity's Transaction Enrollment Tool
  • Pharmacy claims and services: Sign-up for EFT by contacting Prime Therapeutics at 1 (844) 765-6827

EFT deposits will be made two business days after the payment issue date to comply with National Automated Clearing House Association (NACHA) guidelines. Note: We will make only credit entries to your designated bank account. If it becomes necessary to initiate a correcting debit, we will notify you in advance.

Updating your EFT information

If you change bank accounts, submit a change request using Availity's Transaction Enrollment Tool.

EFT Hotline Number

Call 1 (800) 662-7534 for missing EFT payment, and bank change request issue - press 1 and leave a detailed message including your name, phone number, and tax ID number.

CCD Re-association data elements

Corresponding ERA (835 V5010) data elements

CCD Record number

Field number

Field name

Data element segment

Data element name

Availity's remittance viewer

5

9

Effective entry date - date the payer intends to provide funds to the payee via EFT

BPR16

EFT effective date

N/A

6

6

Amount

BPR02

Payment amount

N/A

7

3

Payment-related information - payment-related ASC X12 data segments

TRN02 and TRN03

EFT Trace Number and Payer Identifier

Check/EFT trace number

HSA account payments

Members can use their Health Savings Account (HSA) funds to make payments to providers for qualified medical expenses. Many of our members who have an HSA as their chosen health plan product use HealthEquity, one of the largest Health Savings Account (HSA) non-bank custodians.

HealthEquity offers the following payment options:

  • Providing debit cards that members can use to pay for expenses from their HSA account
  • Reimbursing members directly for any out-of-pocket expenses they incurred once the claim is processed
  • Paying the provider directly through the HealthEquity virtual card payment process, once the claim has been processed

If a member chooses the virtual card payment process (PDF), the provider will receive a payment voucher via fax. If HealthEquity does not have the provider's fax number, they will mail the initial payment voucher to the address indicated on the claim and will then work with the provider to set up the faxing option for future use. The voucher indicates the member's account information and the payment amount with instructions for how to obtain the payment using a merchant terminal.

The virtual card option benefits include faster payment delivery and funds availability, no trips to the financial institution to make deposits, plus better fraud protection. Contact HealthEquity Customer Service at (866) 919-0537 with any payment questions.

BridgeSpan Health receives an administrative fee for each HealthEquity integrated HSA. The fee allows for a high level of support and integration between BridgeSpan health plans and HealthEquity's health savings accounts.