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Billing and Claims

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Billing and Claims

Commercial
Medicare

Electronic Funds Transfer

Electronic Funds Transfer (EFT)

EFT is a quick and easy way for participating providers to receive payment for the claims submitted to ConnectiCare. When you select to receive funds electronically, you can expect to receive your payment directly into your bank account within 48 hours of each claims payable date.

Simply fill out the Electronic Funds Transfer (EFT) Form and return it to ConnectiCare’s Finance Department. (ConnectiCare may also ask that you provide us with a spec sheet from your bank or a copy of a voided check.) In general, you will begin receiving payment electronically within 10 business days from the date we receive your completed form.

Do I have to submit claims electronically in order to receive EFT?
No. EFT is not dependent upon electronic claims submission. Claims which are submitted in paper format may also be reimbursed via EFT.

Will I receive EFT for all types of claims?
Yes, ConnectiCare coordinates EFT for claims for all product types.

Will EFT affect the way I receive my explanation of payment (EOP)?
Through your secure provider website account, your EOP is available online 3 days following the claims payment date. You will no longer receive via mail a paper copy of your explanation of payment (EOP). To view your EOP statements online, simply sign in to your provider website account. If you are not yet registered, register today.

I have more questions.
If you have additional questions regarding EFT, please call 800-828-3407.

Electronic Data Interchange Information

Electronic Data Interchange (EDI) Information

Electronic Data Interchange is a way of connecting your systems to our systems to exchange information quickly and efficiently, and typically at high volume. You can submit claims, receive remittance advice, and perform other transactions using EDI.

What will I need to use EDI with ConnectiCare?
To begin using EDI, an electronic connection must be established between your office and ConnectiCare. To accomplish this you will need some basic equipment, including a:

•  Computer
•  Modem
•  Dedicated Direct Telephone Line
•  Practice Management System Software

EDI Clearinghouses

An EDI connection is established with ConnectiCare through a clearinghouse. EDI clearinghouses are companies that can connect your office to several different payors or other organizations, including ConnectiCare. Currently, ConnectiCare has relationships with several different clearinghouses. Please see below for a list of clearinghouses with connectivity to ConnectiCare.

Interested?

To discuss how to best connect your office with ConnectiCare using EDI, call 800-828-3407.

Filing Limits

Filing limits

The filing limit for claims submission is 180 days from the date the services were rendered. (The filing limit for some self-funded groups may vary.) For more information, contact Provider Services at 860-674-5850 or 800-828-3407. (New York providers should refer to their contract as the filing limit in some contracts may vary.)

Filing Limit Denial: Acceptable Documentation for Appeal

A computer printout from a provider’s own office system is not acceptable proof of timely filing of claims.

When submitting the Provider Appeal Request Form, you must provide proof of timely filing. Acceptable documentation includes:

• Electronic vendor statement (“Acceptance Report by Providers”) showing that the data was successfully received by ConnectiCare (i.e., #R022)
• Denial letter, Explanation of Benefits, or take back notice from another carrier that was submitted within six (6) months of the date of denial

Send to:

Provider Appeals Coordinator
ConnectiCare
175 Scott Swamp Road
Farmington, CT 06032-3124

PPM/2.10

Refunds/Overpayments

Refunds/overpayments

In the event that you receive an overpayment of claims, duplicate payment, or payment for claims that were reimbursed inaccurately, we request you refund the appropriate amount to ConnectiCare. We will identify and request reimbursement of overpayments within 18 months of the date the claim was paid. No requests for refunds beyond this time limit will be requested, unless the overpayment is due to fraudulent billing activity.

If you would like ConnectiCare to take back the overpayment through future claims payment, or when you identify an overpayment prior to a notification from ConnectiCare:

• Complete a Standard Provider Refund Form
• Send to: ConnectiCare, Inc., P.O. Box 416608, Boston, MA 02241-6608
• Send a copy of the Explanation of Payment
• Provide an explanation of why you are sending the refund

In the event that we notify you in writing that ConnectiCare has identified a payment error in an amount exceeding the amount due to you, you will be responsible for making the applicable refund.

• Refunds must be received within thirty (30) days of receipt of notice, unless alternative arrangements are made in writing and accepted by ConnectiCare.
• If payment is not received within the 30-day time frame, the overpayment amount will be taken back through future claims payment.
• If you dispute the overpayment amount, you must notify ConnectiCare in writing within fifteen (15) days of the initial overpayment notice.

In the event that you fail to respond to the notice for refund, ConnectiCare retains the right to terminate your participation with ConnectiCare and/or to offset the amount due ConnectiCare against any monies due to you, including but not limited to any withhold return due to you.

ConnectiCare reserves the right to utilize third-party vendors to identify claim overpayments made to providers. View complete listing of approved vendors online, or call Provider Services at 800-828-3407.

PPM/10.16

Coordination of Benefits

Coordination of benefits

Coordination of benefits (COB) is a way of determining the order in which benefits are paid and the amounts that are payable when a member is covered under more than one group health plan.

Note: Any work-related injury is not a covered benefit. Claims are not coordinated for workers’ compensation.

Entitlement of member
If a member is entitled to receive medical/health benefits under another group insurance plan, the benefits under the ConnectiCare plan will be coordinated with benefits under the other plan(s), up to 100% of the member’s responsibility. In no event shall ConnectiCare be liable for more than it would have been liable as the primary payer. The member:

• Must notify ConnectiCare of other coverage and will be responsible for payment of all non-covered services; and
• Shall never be liable for more than their applicable cost-share (e.g., copayments, coinsurance, deductibles, etc.) under their ConnectiCare plan.

Provider responsibility

• You must bill the other health plan insurance/insurer first, when ConnectiCare is secondary carrier.
• When submitting a claim to ConnectiCare as secondary carrier, you must also include the claim summary or explanation of benefits (EOB) from the other health plan.
• You must indicate the other health plan insurance on the bill you submit to ConnectiCare.
• You must submit the procedure codes which are required per your contract with ConnectiCare. If you submit procedure codes which are not on your contract/fee schedule, the claim will be denied.

Effect on payment

ConnectiCare as primary carrier: ConnectiCare will pay the full contracted, allowable amount minus applicable cost-sharing or adjustments. (The patient may receive reimbursement from the secondary carrier for any out-of-pocket expenses incurred, such as the copayments, coinsurance, and deductibles.)
ConnectiCare as secondary carrier:
- Payment will not be made until we receive a copy of the claim summary or explanation of benefits (EOB) indicating the amount paid by the primary carrier.
- ConnectiCare will pay up to the member’s responsibility under the primary carrier or ConnectiCare’s contracted amount, which ever is lower.
- We recommend that the copayment not be collected at the time of service. Once you receive payment from all carriers, determine if there is any remaining billable balance. Most balance billing occurs when the member has a deductible that needs to be satisfied, such as a Medicare Part B deductible, or a commercial carrier deductible
- The filing limit for claims where ConnectiCare is secondary is 180 days after the issue date of the last claim summary or EOB received from the primary carrier. Claims denied as beyond the filing limit by the primary carrier will not be accepted for payment by ConnectiCare. Note: If the member has medical coverage under their auto carrier, the auto carrier would be primary for claims related to the auto accident, up to the policy maximum.
- Dual ConnectiCare coverage: ConnectiCare will coordinate benefits under the secondary plan, after the first ConnectiCare plan has paid. For example, under the first ConnectiCare plan the patient is responsible for a copayment and under the second plan, that copayment and/or any applicable balance will be paid, providing policy limitations/guidelines are followed. You should not take the primary copayment up-front since this amount will be paid to you under the secondary plan. Otherwise, you will be responsible for reimbursing the member once the secondary payment is made. (When ConnectiCare payments are capitated, you should manually adjust your books for any balance due from ConnectiCare.)

Order of benefit determination
Following are some generally applicable rules for determining which plan is primary or secondary. If you have any questions after reading this manual, please contact Provider Services at 860-674-5850 or 800-828-3407.

Member with commercial plan	Primary carrier
Subscriber	ConnectiCare
Subscriber’s spouse without other group health insurance	ConnectiCare
Subscriber’s spouse with other carrier group health insurance	Other
Dependent child when both parents have insurance, and are not separated or divorced	Determined by the COB Birthday Rule* (unless the Gender Rule** applies)

Member with commercial plan	Primary carrier
Child whose parents are divorced, legally separated, or whose health coverage has been ordered by the courts.	Health plan/insurer of the parent whom the court has care ordered to provide coverage for the child.
Child whose parents are divorced or legally separated. Parent with custody is not remarried.	Insurer of parent with legal custody
Child whose parents are divorced or legally separated. Parent with legal custody is remarried.	Four (4) levels of COB: • First, the plan of the parent custody • Second, the plan of the spouse of the parent with custody • Third, the plan of the parent without custody • Plan of the spouse of the parent without custody

Member with Medicare	Primary carrier
Active employee is 65 or older and if the group he/she works for has fewer than 20 employees	Medicare
Retired employee is eligible for Medicare and has Medicare Parts A & B	Medicare

Member with Medicare carrier	Primary carrier
Individual entitled to Medicare due to end-stage renal disease (ESRD)	First 30 months ConnectiCare commercial plan, then Medicare
Retired spouse of active employee has own retiree policy through previous employer and has Medicare Parts A & B.	ConnectiCare commercial plan is primary, Medicare is secondary, the retiree policy is tertiary
Spouse of active employee is under 65 and eligible for Medicare due to total disability.	ConnectiCare commercial plan is primary (as long as the employer group has over 100 employees); Medicare is primary if the employer has less than 100 employees
Spouse (over 65) of active employee who is under 65.	ConnectiCare commercial plan is primary and Medicare is secondary

* Birthday rule: Primary carrier is the health plan/insurer of the parent whose month and day of birth occurs earlier in the calendar year. If parents share the same birthday, the primary carrier is the health plan that has been in effect longer.

**Gender Rule: For dependent children covered by each parent’s policy when the parents are not divorced or separated, the plan of the father is primary over the mother’s plan.

Note: Pursuant to Connecticut COB rules and federal law, ConnectiCare does not coordinate benefits under a ConnectiCare SOLO individual plan or Exchange plan, with other group plans or other individual plans with the exception of Medicare. If a ConnectiCare SOLO or Exchange member is also enrolled in a Medicare plan, Medicare will be the primary plan.

PPM/3.13

Consolidated Appropriations Act/No Surprise Billing Info

What Providers Need to Know About the No Surprises Act

Frequently Asked Questions

Q. What is the No Surprises Act?

The No Surprises Act, (part of the Consolidated Appropriations Act, 2021 (CAA-21)), effective for claims with a date of service Jan. 1, 2022, and forward, includes:

Protections for individuals from getting surprise medical bills after receiving emergency medical care and certain related services.
Provisions for non-participating providers to negotiate and/or dispute certain reimbursements they receive from insurance companies.

Q. When did this act start?

Jan. 1, 2022.

Q. What types of services are covered by the No Surprises Act?

Under the No Surprises Act, out-of-network providers are prohibited from billing patients more than their in-network cost-sharing amounts for:

All out-of-network emergency facility and professional services.
Post-stabilization care at out-of-network facilities (until the patient can be safely transferred to an in-network facility).
Air ambulance services (transports) in emergency and non-emergency situations.
Out-of-network services delivered at, or ordered from, an in-network facility.

Q. Does the No Surprises Act cover regular ground ambulance services?

No.

Q. How will the No Surprises Act change how payer organizations, such as EmblemHealth and ConnectiCare, collect and pay our providers for services?

Surprise out-of-network services can no longer be billed directly to the patient. Payer organizations have 30 days to make an initial payment or send a notice of denial to the provider.

Q. How is the initial payment of a claim determined?

The initial payment is based on the “qualifying payment amount,” which is the median rate in each geographical area and insurance market for a particular service. If the provider feels the amount the payer organization paid is too low based on their existing rates and their usual medical billing amounts, the No Surprises Act allows for a new process, beginning with an open negotiation process.

Q. How do providers initiate the open negotiation period with the health plan?

Providers have the option to begin a 30-day “open negotiation,” during which the provider and the payer can negotiate on a mutually agreeable payment amount. The open negotiation request must be sent within 30 business days of receipt of the initial payment or notice of denial. The surprise billing open negotiation form must be used to initiate the process and can be found here: Open Negotiation Notice (dol.gov).

Providers can submit the official request form for negotiation by, fax, mail, or email at the contacts below:

FAX:

HMO Provider Contact Center: 212-510-4981
PPO Provider Contact Center: 212-510-3184
ConnectiCare Provider Contact Center: 860-674-2232

MAIL:

HMO (HIP) PO Box 2845, New York NY 10116
PPO (GHI) PO Box 2832, New York NY 10116
ConnectiCare Commercial PO Box 546, Farmington, CT 06034-0546

EMAIL:

Q. What if an agreement cannot be reached on the reimbursement amount?

At the end of the negotiation period, if the health plan and provider or facility haven’t agreed on a payment amount, either party can begin the independent dispute resolution (IDR) process.

Q. What standards must be met to start an independent dispute resolution (IDR)?

A dispute can’t be started until the required 30-business-day open negotiation period has ended. Then, the dispute must be started within four business days after the open negotiation period has ended, except in the circumstance described in this memorandum (PDF).

Q. How does the independent dispute work?

Implementation and enforcement of the No Surprises Act involves both federal and state governments. Generally, the law assigns enforcement to the states but calls for federal enforcement where states are unwilling or unable to take it on. Many states are sharing enforcement responsibility with the federal government, sometimes with a collaborative enforcement agreement. In addition, almost half of all states have specified state laws that will be used to determine payments from insurers (generally state-regulated insurers) to out-of-network providers in lieu of the federal independent dispute resolution (IDR) system. These states generally use either a standard payment rule, a state-specific dispute resolution process, or a hybrid of the two to determine the out-of-network payment rate.

State	What is state's overall strategy for No Surprises Act enforcement?	Notes
Connecticut	Shared	Federal enforcement for some surprise billing provisions. State enforcement for some surprise billing provisions.
Massachusetts	Shared (collaborative)	Federal enforcement for some surprise billing provisions. State enforcement for some surprise billing provisions, with use of a collaborative enforcement agreement.
New Jersey	Shared (collaborative)	Federal enforcement for some surprise billing provisions. State enforcement for some surprise billing provisions, with use of a collaborative enforcement agreement.
New York	Shared	Federal enforcement for some surprise billing provisions. State enforcement for some surprise billing provisions.

Q. What is the definition of shared (collaborative enforcement) and shared enforcement?

Shared (collaborative enforcement) is when enforcement is shared and a collaborative enforcement agreement between the state and the federal government will be used to allocate responsibilities for at least some designated provisions. For example, for enforcement against providers, the state might investigate and issue voluntary enforcement letters, and the federal government would impose civil monetary penalties as needed.

Shared enforcement is when some provisions are enforced by the state and some by the federal government.

This map shows more information on how the No Surprises Act is enforced by each state.

Q. How are the state bureaus contacted?

Most states are responsible for enforcing Affordable Care Act (ACA) standards that apply to fully insured health plans, including those sold to individuals and small employers. These standards include the requirement that plans cover Essential Health Benefits and the prohibition on plan designs that discourage enrollment from people with significant health needs. In states that fail to enforce the ACA standards, the U.S. Department of Health and Human Services is responsible for enforcement. See the table below for contact information for state departments of insurance.

State	Department of Insurance Website
Connecticut	ct.gov/cid/site/default.asp
Massachusetts	mass.gov/ocabr/government/oca-agencies/doi-lp/
New Jersey	state.nj.us/dobi/index.html
New York	dfs.ny.gov/

Q. For the states with a shared/collaborative strategy to enforce the No Surprises Act, how do you determine whether the state or federal independent dispute resolution (IDR) process should be used?

If your state is in the “Bifurcated Process” column, you should review the state law or All-Payer Model Agreement and, if necessary, consult with the proper state authorities on whether the state or the federal IDR process applies to the particular payment dispute at issue.

Q. How does the federal independent dispute resolution (IDR) process work?

The IDR process is outlined here:

Ending Surprise Medical Bills (Centers for Medicare & Medicaid Services (CMS))
Start a Dispute (U.S. Dept. of Health and Human Services)

Q. What types of services are covered by the federal IDR process?

Use federal IDR for:

Self-insured plans sponsored by private employers, private employee organizations, or both in all states, except in cases in which a self-insured plan has opted into a specified state law, in a state that permits these plans to opt in, or when an All-Payer Model Agreement applies.
Health benefits plans offered under 5 U.S.C. 8902 in all states, except in cases where an Office of Personnel Management (OPM) contract with a Federal Employee Health Benefits (FEHB Carrier includes terms that adopt the state process.
Where the plan or issuer and provider or facility are in different states, the federal IDR process will apply.
Air ambulance and out-of-area (outside NY, CT, MA, NJ) regardless of line of business.

Go to the Centers for Medicare & Medicaid Services (CMS) website for more information.

Q. What types of services are NOT covered by the federal IDR process?

The federal IDR process does not apply to items and services payable by Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), or TRICARE.
The federal IDR process also does not apply in cases where a specified state law or All-Payer Model Agreement under Section 1115A of the Social Security Act provides a method for determining the total amount payable under a group health plan or group or individual health insurance coverage with respect to the out-of-network items and services furnished by the provider or facility.

Q. Do I need to notify the health plan when I file a federal IDR?

Yes. Send a copy of your federal Notice of IDR Initiation to us the same day you file it. Please send all IDR actions to nsa_idrsubmission@emblemhealth.com.

Q. Where can I find more information on this topic?

General Information:

You can learn more about the Federal No Surprises Act process on the Centers for Medicare & Medicaid Services (CMS) website.

Video: 5 Things to Know about the No Surprises Act Taking Effect in 2022 (U.S. Dept. of Health and Human Services, YouTube)

Video: The No Surprises Act is in effect. What physicians need to know. (American Medical Association (AMA))

Member Information

EmblemHealth: Consumer Protections (emblemhealth.com)

ConnectiCare: Important Legal Notices for ConnectiCare Members (connecticare.com)

This information was compiled December 2022 and is subject to change, as there may be amendments to this language and/or the Act itself. We will make every effort to update this language as necessary.

Administrative Procedures: Claims

Claims

The Claims Department processes all medical claims received from participating providers, unless a contractual arrangement exists to delegate claims payment to a participating entity. All claims are entered into the data processing system where an online claims history is maintained for twenty-four (24) months. Claims are adjudicated according to the provider’s contractual agreement and the member’s benefits. You may direct any questions regarding claims to Provider Services at 877-224-8230.

ConnectiCare has a fraud and abuse hotline that is available to members, providers, employees, and government officials. If you suspect fraud or abuse, contact our Special Investigations Unit at 888-4KO-FRAUD (888-456-3728) or via email at kofraud@emblemhealth.com.

Medicare PPM/7.20

Claims Submissions

Claim submission

Electronic claim submission:
ConnectiCare strongly encourages the electronic submission of claims as the most efficient, cost-effective means of claim submission. We receive claims from the following clearinghouses:

Change Healthcare 877-469-3263 changehealthcare.com	Capario 800-586-6870 capario.com	The SSI Group, Inc. 800-881-2739 thessigroup.com
Computer Innovations 203-272-1554 salfusco40@aol.com	PNT Data 860-257-2030 PNTData.com	Medical Claim Corp. 800-822-9916
Legacy Services 214-440-3100

ConnectiCare’s payer ID number for electronic claims submission: 78375
For additional information, contact Provider Services at 877-224-8230.

Paper claim submission
You may submit paper claims by completing a CMS 1500 form or UB-04 form, as appropriate. The following information must be indicated on the claim, in the box indicated, in order for ConnectiCare to accept and process the claim. If all the information outlined below is not present and correct on the claim form, it will be returned to you for the required information.

CMS 1500: Required information	Box
Member ID# (including 2-digit suffix)	1a
Patient's name	2
Other insurance (for internal routing purposes only)	9 & 10
Referring physician's name	17
Referring physician's provider ID#	17a
Diagnosis code(s) (accurate to the 4th or 5th digit)	21
Dates of service	24a
Place of service (location code)	24b
CPT/HCPCS code	24d
Charges	24f
Federal tax ID#	25
Provider name, full address, and ConnectiCare provider ID number (6 or 10 digits; a.k.a. pin number), and site number (if applicable)	33

Submit claims to:

ConnectiCare
P.O. Box 4000
Farmington, CT 06034-4000

Paper claims should not be submitted by FAX. If we receive a FAX that is not readable, we will need to request that the provider resubmit a hard copy, adding to the processing time for the claim.

UB04: Required information	Box
Facility name and full address	1
Type of bill	4
Federal tax ID#	5
Statement covers period	6
Patient's name	12
Revenue code	42
CPT or HCPCS/Rates (if applicable)	44
Total charges	47
Indication of dual payers (so that claims are appropriately routed through the Coordination of Benefits workflow)	50
ConnectiCare provider ID number (6 or 10 digits)	51
Member ID#	60
Principle diagnosis code	67
ICD-9 Procedure Code	80/81

Medicare PPM/2.10

Filing Limits

Filing limits

The filing limit for claims submission is 180 days from the date the services were rendered. For more information, contact Provider Services at 877-224-8230.

Filing limit denial: Acceptable documentation for appeal
When a claim has been denied because it was submitted beyond the filing limit, you may appeal our decision. In order to appeal, you must provide a letter explaining why payment is warranted and one of the following examples of acceptable documentation:

• ConnectiCare’s Claims Status Report, showing the claim was filed timely
• Electronic vendor report (“Acceptance Report by Providers”) showing that the data was successfully transmitted to ConnectiCare (i.e., #R022)
• Denial letter, Claim Summary or Explanation of Benefits (EOB) from another carrier that was submitted within six (6) months of the date of denial

Send to:

ConnectiCare
175 Scott Swamp Road
Farmington, CT 06032-3124

Medicare PPM/3.13

Claims Payment

Claims payment

• ConnectiCare processes claims daily and issues remittance checks twice a week (some exceptions for holiday weeks). Generally, the remittance and checks are mailed first class within 48 hours following the day on which they are produced. ConnectiCare cannot pull a check or an EOP for a provider to pick up.
• All providers will be paid in accordance with payment arrangements for Medicare beneficiaries as set forth in the Medicare Advantage Schedule of Payments for Medicare Advantage plan members, and incentive arrangements (if any) as set forth therein.
• Providers shall ensure that any payment and incentive arrangements they have with subcontractors are specified in a written agreement.

Medicare PPM/2.10

Fraudulent Statement and Claims

Fraudulent statements and claims

• Any person who knowingly and with intent to defraud any insurance company or other person files a statement or claim containing any false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime punishable under applicable laws.
• All providers acknowledge that ConnectiCare is receiving federal funds and that payments to providers for covered services are in whole or in part, from federal funds.

Medicare PPM/2.10

Refund/Overpayments

Refunds/overpayments

In the event that you should receive an overpayment of claims, duplicate payments or payment for claims that were reimbursed inaccurately, we request that you refund the appropriate amount back to ConnectiCare.

When forwarding a refund please be sure to:

• Complete a Standard Provider Refund Form
• Send a copy of the remittance
• Provide an explanation of why you are sending the refund (e.g., duplicate payment; billed claim in error)
• Send the refund to:

ConnectiCare VIP Medicare Advantage Claims Refund
P.O. Box 416947
Boston, MA 02241-6947

In the event that we notify you in writing that ConnectiCare has identified a payment error in an amount exceeding the amount due to you, you will be responsible for making the applicable refund. Such refunds must be made to ConnectiCare within thirty (30) days of receipt of the written notice, unless alternative arrangements are made in writing and accepted by ConnectiCare. If you dispute the overpayment amount, you must notify ConnectiCare in writing within fifteen (15) days of the initial overpayment notice.

Medicare PPM/4.12

Corrected Claims/Resubmissions

Adjustments/corrected claims/resubmissions

To ensure the Claims Department has adequate information to process claim adjustments and corrected claims in an accurate and timely manner, ConnectiCare requires that requests be submitted via the Claim Resubmission Request Form.

Adjustments (review of a claims processing error) — The provider requests that ConnectiCare reconsider a denied claim or the amount paid based on the original claim submission. An adjustment should be requested if the claim was not paid for all reimbursable services or has been denied inappropriately for reasons such as member eligibility, duplicate services, retroactive referrals and authorizations, and retroactive contract changes. Adjustments may not be requested for services denied due to claims payment policies. Refer to Administrative Appeals within this section.

ConnectiCare reserves the right to charge providers a $15 per claim fee for high-volume (20 or more claims) bulk billing errors for electronically submitted claims.

Corrected claims (review of a claims billing error) — The provider requests that ConnectiCare reconsider a claim based on incorrect, new, or missing data that was not submitted with the original claim. Clinical documentation should not be submitted with corrected claims.

The process for submitting adjustments, corrected claims, and resubmissions is the same, as outlined below:

• If submitting a request for a corrected claim, also attach a copy of the corrected claim form (CMS 1500 or UB-04).
• There is a 1-year adjustment limit from the date of the original Explanation of Payment.
• Submit to:

ConnectiCare
P.O. Box 4000
Farmington, CT 06034-4000

• Adjustments and corrected claims may not be submitted electronically.
• Resubmission of claims that have not yet been paid may be submitted electronically. ConnectiCare’s 180-day filing limit (from date of service) applies.

Medicare PPM/3.11

Administrative Appeals

Administrative appeals

ConnectiCare will provide decisions on administrative appeals within ninety (90) calendar days after receipt of the appeal request.

Administrative appeals — The provider requests reconsideration of a claim denied for administrative purposes (e.g., filing limit, coding edits).

Review the Explanation of Payment to determine why the claim was denied or why only partial payment was made.
Complete the Provider Appeal Request Form.
The following is required for claims reconsideration:
- Operative Report or office chart notes, as applicable
- Proof of timely filing if appealing a claim that was denied for being submitted beyond the filing limit. (A computer printout from a provider’s own office system is not acceptable proof of timely filing of claims.)
There is a 180-day limit for appeal from the date of the initial denial and there is only one level of appeal for administrative appeals.
If the appeal is the result of incorrect coding, the provider will receive notification to submit a corrected claim. Please note, application of the appropriate modifier is the responsibility of the provider. ConnectiCare provides coding resource information on our website.
If additional documentation is requested by ConnectiCare, the documentation must be provided within 30 calendar days of the request. If received beyond this time frame, the denial will be upheld and the request will be closed.
Attach additional information to a copy of the original claim and submit it to the address shown below, or call 877-224-8230.

Provider Appeals Coordinator
ConnectiCare
175 Scott Swamp Road
Farmington, CT 06032-3124
Fax: 860-674-7035

Medicare PPM/5.11

Billing of Members

Billing of members

Copayments:
Participating providers are required to collect copayments from members for services performed in the office setting for which the provider submits a claim. (The copayment amount/applicable services, as stated on the ID card, are governed by the member’s Evidence of Coverage or other legal documents, as applicable.) Services that require a copayment include, but are not limited to, office visits, pain management services, and diagnostic/therapeutic procedures.

Some examples of services that generally do not take a copayment are as follows:

• Care related to pregnancy, after the initial office visit copayment is made;
• Certain antepartum care: amniocentesis, biophysical profile, fetal ultrasound examinations, and fetal stress/non-stress test;
• Chemotherapy administration services, billed as a single service and not part of an office visit;
• Immunization codes;
• Laboratory codes and/or venipuncture, if no other service is billed; and
• Mammography screening.

Note: In any case, the member is only responsible for one copayment per day, per billing provider/group in the same specialty, for applicable services provided. For example, when physicians bill for a preventive visit in addition to an office visit, on the same date of service, only one copayment should be collected.

Coinsurance:
ConnectiCare offers plans that have coinsurance requirements. To ensure a more efficient billing process, bill ConnectiCare for services rendered prior to taking any cost-sharing payments from members. This will allow you to verify whether the member has coinsurance requirements. When you receive your remittance from us, you may then bill the member for the portion of the bill for which he/she is responsible, as indicated on the EOP.

Covered Services:
Participating providers may not bill members for any service that is covered under the member’s ConnectiCare plan. Nothing in this section is intended to restrict or prohibit providers from billing a member for any applicable copayment, coinsurance, or deductible for certain covered services, as required under the member’s plan.

Denied Services:
Members should not receive a statement or be billed, unless the service has been denied with an explanation code that allows the member to be billed. If you’re not sure of whether member liability exists, contact Provider Services before billing a member.

Note: Prior to initiating services that are not covered under a member’s plan, the physician or other health care provider must advise the member that the service is not covered, that the member will be held responsible for the associated costs, and the member must agree to be financially liable for those costs prior to receiving the services.

Refunds/overpayments by members:
If you receive an overpayment from a member that exceeds the cost-share for which they are responsible according to their benefit plan, we request that you refund the appropriate amount back to the member in a timely manner. You can verify whether or not a member is due a refund by referring to your Explanation of Payment and reconciling it against your patient accounts.

Medicare and Medicaid-eligible members designated as Qualified Medicare Beneficiary
Medicare providers under their ConnectiCare contract are required to see all ConnectiCare Medicare Advantage plan members including those who are dual eligible for Medicare and Medicaid.

Providers are also reminded that dual eligible members who are designated as Qualified Medicare Beneficiaries (QMB or QMB+) cannot be billed for any Medicare cost-share. The bill of service for these members must be submitted to Medicaid for reimbursement.

For guidance in the prohibition of balance billing of QMBs, please refer to this Medicare Learning Network document.

Medicare PPM/4.17

Coordination of Benefits

Coordination of benefits

Coordination of benefits (COB) is a way of determining the order in which benefits are paid and the amounts that are payable when a member is covered under more than one group health plan.

Note: Any work-related injury is not a covered benefit. Claims are not coordinated for workers’ compensation.

Provider responsibility

• You must bill the other health plan insurance/insurer first, when ConnectiCare is secondary carrier.
• When submitting a claim to ConnectiCare as secondary carrier, you must also include the Claim Summary or Explanation of Benefits (EOB) from the other health plan.
• You must indicate the other health plan insurance on the bill you submit to ConnectiCare.
• You must submit the procedure codes which are required per your contract with ConnectiCare. If you submit procedure codes which are not on your contract/fee schedule, the claim will be denied.

Effect on payment

• ConnectiCare as Primary Carrier: ConnectiCare will pay the full contracted, allowable amount minus applicable cost-sharing or adjustments. (The patient may receive reimbursement from the secondary carrier for any out-of-pocket expenses incurred, such as the copayments, coinsurance and deductibles.)
• ConnectiCare as Secondary Carrier:

• Payment will not be made until we receive a copy of the Claim Summary or Explanation of Benefits (EOB) indicating the amount paid by the primary carrier.
• ConnectiCare will pay up to the member’s responsibility under the primary carrier or ConnectiCare’s contracted amount, whichever is lower.
• We recommend that the copayment not be collected at the time of service. Once you receive payment from all carriers, determine if there is any remaining billable balance. Most balance billing occurs when the member has a deductible that needs to be satisfied, such as a Medicare Part B deductible, or a commercial carrier deductible.
• The filing limit for claims where ConnectiCare is secondary is 180 days after the issue date of the last Claim Summary or EOB received from the primary carrier. Claims denied as beyond the filing limit by the primary carrier will not be accepted for payment by ConnectiCare.

Note: If the member has medical coverage under their auto carrier, the auto carrier would be primary for claims related to the auto accident, up to the policy maximum.

• Dual ConnectiCare Coverage: ConnectiCare will coordinate benefits under the secondary plan, after the first ConnectiCare plan has paid. For example, under the first ConnectiCare plan the patient is responsible for a copayment and under the second plan, that copayment and/or any applicable balance will be paid, providing policy limitations/guidelines are followed. You should not take the primary copayment up front since this amount will be paid to you under the secondary plan. Otherwise, you will be responsible for reimbursing the member once the secondary payment is made.

Member with commercial plan	Primary carrier
Subscriber	ConnectiCare
Subscriber’s spouse without other group health insurance	ConnectiCare
Subscriber’s spouse with other carrier group health insurance	Other
Dependent child when both parents have insurance, and are not separated or divorced	Determined by the COB Birthday Rule* (unless the Gender Rule** applies)

Member with commercial plan	Primary carrier
Child whose parents are divorced, legally separated, or whose health coverage has been ordered by the courts.	Health plan/insurer of the parent whom the court has care ordered to provide coverage for the child.
Child whose parents are divorced or legally separated. Parent with custody is not remarried.	Insurer of parent with legal custody
Child whose parents are divorced or legally separated. Parent with legal custody is remarried.	Four (4) levels of COB: • First, the plan of the parent custody • Second, the plan of the spouse of the parent with custody • Third, the plan of the parent without custody • Plan of the spouse of the parent without custody

Member with Medicare	Primary carrier
Active employee is 65 or older and if the group he/she works for has fewer than 20 employees	Medicare
Retired employee is eligible for Medicare and has Medicare Parts A & B	Medicare

Member with Medicare Carrier	Primary carrier
Individual entitled to Medicare due to end-stage renal disease (ESRD)	First 30 months ConnectiCare commercial plan, then Medicare.
Retired spouse of active employee has own retiree policy through previous employer and has Medicare Parts A & B.	ConnectiCare commercial plan is primary, Medicare is secondary, the retiree policy is tertiary.
Spouse of active employee is under 65 and eligible for Medicare due to total disability.	ConnectiCare commercial plan is primary (as long as the employer group has over 100 employees); Medicare is primary if the employer has less than 100 employees.
Spouse (over 65) of active employee who is under 65.	ConnectiCare commercial plan is primary and Medicare is secondary.

* Birthday Rule: Primary carrier is the health plan/insurer of the parent whose month and day of birth occurs earlier in the calendar year. If parents share the same birthday, the primary carrier is the health plan that has been in effect longer.

**Gender Rule: For dependent children covered by each parent’s policy when the parents are not divorced or separated, the plan of the father is primary over the mother’s plan.

Note: Pursuant to Connecticut COB rules and federal law, ConnectiCare does not coordinate benefits under a ConnectiCare SOLO individual plan with other group plans or other individual plans. If a ConnectiCare SOLO member is also enrolled in a Medicare plan, Medicare will be the primary plan.

Medicare PPM/3.13

provider

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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.