Submit Claims

To expedite payments, we suggest you submit claims electronically, and only submit paper claims when necessary. You can now submit claims through our online portal.

Send claims within 120 days for WellSense.

In order to pay your claims quickly and accurately, we must receive them within 120 days of the date of service.
Please submit a:

  • Single claim for each patient
  • Separate claim form for each provider who saw a patient
  • Separate claim form for each site where a patient received services

Submitted claims must:

Meet all prior authorization requirements and include the prior authorization number

Include both your National Provider Identifier (NPI) and tax ID numbers

For more information, please see the Provider Manual, Section 9, Billing and Reimbursement.

For earlier submissions and faster payments, claims should be submitted through our online portal or register with Trizetto Payer Solutions here. Or use the following clearinghouses:

  • Gateway EDI
  • NEHEN (New England Healthcare EDI Network)

Submitting claims through the portal means you can:

  • Get paid up to a week faster on clean claims
  • Reduce your administrative costs
  • Minimize typos and errors
  • Correct claims electronically

You can also submit claims through billing agencies, such as Affiliated Professional Services, Athenahealth or ClaimRemedi, LogixHealth, Hill Associates (a.k.a., AdvantEdge), and ViaTrack (QSI).

Electronic Claim set up is simple and only takes five minutes.

Call the Provider Service Center at 877-957-1300 for more information. And see our EDI FAQ and our companion guides:

Send new paper claims via U.S. mail to the address below for covered services given to WellSense Health Plan members. Sending claims via certified mail does not expedite claim processing and may cause delays.

WellSense Health Plan
Claims Department
PO Box 55049
Boston, MA 02205-5049

Enter your claims data on the CMS-1500 form. You can enter your claims data directly on the CMS-1500 form from your computer. Just save the form to your computer, fill in the data, print it, and mail it to the address above.

See detailed instructions for filling out this form.

Returned Checks

If you receive a check with the wrong pay-to information, send it back to us at the above address along with the correct provider pay-to-information. Then we will reissue the check.

Refunding Overpayments

If you received an overpayment, complete this form to credit the money back to us. Please return the form within 60 days of receipt of the overpayment by mail or fax.

WellSense Health Plan
Credit Balance Department
PO Box 55049
Boston, MA 02205-5049

Log in to the portal to see the status of a claim. Just enter your patient’s member ID number or claim number. You can also:

  • Download claims reports – log in to get standard claims reports.
  • Get payment history – log in in to request to request a remittance report and an explanation of benefits.

If you are not a WellSense network provider and will be administering a one-time service to a member, you must complete this Non-Participating Provider Activation Form to receive payment.

Fax the completed form along with your W-9 form to 617-897-0845, to the attention of the Provider Enrollment Department.

Prior Authorization

You must receive prior authorization before delivering services to a Well Sense Health Plan member. Use the Universal Prior Authorization Form or call 877-957-1300 Option 3.

Please note: If you do not obtain prior authorization, your claim may be denied, unless the claim is for emergency care.

You must correct claims that were filed with incorrect information, even if the claim has been paid.

The most common reasons we reject claims are:

  • The NPI is incorrect, is not listed on the claim or does not match the recorded tax identification number registered in our system
  • Invalid member ID number
  • The original claim number is not included on a void, replacement or corrected claim
  • The EDI void and replacement requests do not include the required information, such as the original claim number
  • Missing NPI Number: If we reject a claim for a missing NPI number, you must send it as a new claim with updated information.

Additional documentation requested: If we requested additional information, simply resubmit the claim with the additional documentation. Do not submit it as a corrected claim.

Electronic Claims

The process for correcting an electronic claim depends on what needs to be corrected:

  • For provider name, NPI number, member name, or member ID number changes, you must first process a void claim, and then file a new claim
  • To correct billing errors, such as the procedure code or dates of services, file a replacement claim

Replacement and void corrections must include the original claim number in a specific position in the 837: Loop 2300, Segment REF – Payer Claim Control Number, with F8 in position 01 (Reference Identification Qualifier) and the original claim number in position 2.

For more information on electronic replacement and void requests, please see the Electronic Health Care Claim Payment / Advice (835) Companion Guide for 5010, page 17, or contact your Provider Relations representative or our EDI department.

Paper Claims

To submit a corrected claim:

  • Print out a new claim with corrected information
  • Write “Corrected Claim” and the original claim number on the top of the claim
  • Circle all corrected claim information
  • Include the plan claim number, which can be found on the remittance advice
  • Denote the item(s) needing correction (please do not hand-write in a new diagnosis, procedure code, modifier, etc.)

Submit the claim in the time-frame specified by the terms of your contract to:

WellSense Health Plan
P.O. Box 55049
Boston, MA 02205

If you don't agree with how a claim was processed, you can request a provider administrative claim appeal using the Request for Claim Review Form. Forms must be submitted with all required information, including but not limited to completion of all fields denoted with an asterisk (*) and the correct Review Type box. If using “Other” on the form, you must document specific information pertaining to your request. Incomplete forms will be returned to the submitting provider for completion and appeal resubmission. Submit the form, the required written narrative and supporting documentation within your contracted timely filing limit to the address below. We have a one-level internal appeals process and will make a determination within 30 days following receipt of the appeal accompanied by the appropriate documentation. A resolution letter describing the decision is mailed to you upon completion of our review.

Please access the Provider Manual for additional information regarding this process.

The following types of provider administrative claim appeals are IN SCOPE for this process:

  • Level of Compensation/Reimbursement
  • Timely Filing of Claims
  • Retroactive Eligibility
  • Lack of Prior Authorization/Inpatient Notification Denials
  • Non-Covered and/or Unlisted Code Denials
  • Other Party Liability (OPL)/Third Party Liability (TPL)/Coordination of Benefits (COB)
  • Provider Audit and Special Investigation Unit (SIU) Appeals
  • Duplicate Claim Appeals

The following are considered Claim Issues and are OUT-OF-SCOPE for this process and must be sent to the appropriate departments:

  • Claim Adjustments
  • Corrected Claims
  • Claim Resubmissions
  • Claims Involving OPL/TPL/COB*

*Note: Claims issues involving OPL/TPL/COB are not necessarily appeals involving OPL/TPL/COB claims. Providers are responsible for sending their requests to the appropriate address via the required method(s).

Mail appeals and supporting documents to:

WellSense Health Plan
Attn: Provider Appeals
PO Box 55049
Boston, MA 02205-5049

Request for Claim Review Form

For more detailed information on appeals, please see section 10 of the Provider Manual.

Overview

ICD-10-CM is a diagnosis classification and coding system developed by the Centers for Disease Control and Prevention (CDC) for use in all U.S. healthcare settings. ICD-10-CM (International Classification of Diseases, 10th Revision, and Clinical Modification) will replace the existing diagnosis code set: ICD-9-CM.

The U.S. Department of Health and Human Services mandated that all HIPAA-covered entities must implement ICD-10-CM for use in standard electronic transactions.

As of October 1, 2015, providers must:

  • Submit outpatient claims with dates of service
  • Submit inpatient claims with dates of discharge
  • Claims submitted for service and discharge dates before October 1, 2015 should be coded using the ICD-9 coding standard

Additional information on ICD-10 is available at the Centers for Medicare & Medicaid Services.

ICD-10 Submission Guidelines Clarification

On May 29, 2015 in Network Notification #18, ICD-10 Submission Guidelines, we communicated in error that we would accept ICD-10 codes comprising upper or lower case characters. We will only accept ICD-10 codes comprising upper case characters. Any claim submitted with ICD-10 codes comprising lower case characters will be denied. Please reference the updated ICD-10 Submission Guidelines and reimbursement policy General Billing and Coding Guidelines, policy number WS 4.17.

ICD-10 Update

In July, CMS announced October 1, 2015 as the new deadline for ICD-10 compliance for providers and payers. HIPAA- covered entities are also required to continue to use ICD-9 codes through September 30, 2015.

Well Sense Health Plan continues to move forward with its commitment to ICD-10 compliance.

Submitting Claims

The following ICD-10 General Submission Guidelines align with CMS:

  • Providers must submit ICD-9 codes for Dates of Service (DOS) or discharge prior to 10/01/2015. Claims containing ICD-10 codes for services prior to October 1, 2015, will be denied**. Providers will be required to re-submit these claims with the appropriate ICD-9 code.
    ** Exception: See section for specific billing guidelines on Inpatient Hospital & Other Bill Types Spanning Implementation Period
  • Providers must submit ICD-10 codes for DOS or discharge on or after October 1, 2015. Claims containing ICD-9 codes for DOS on or after October 1, 2015 will be denied. Providers will be required to re-submit these claims with the appropriate ICD-10 code.
  • We will deny all claims that are billed with both ICD-9 and ICD-10 diagnosis codes on the same claim.
  • We will only accept ICD-10 codes composed of upper case characters. We will deny any claim that is submitted with ICD-10 codes composed of lower case characters or a mix of both upper and lower case characters.

Impact to Providers

Implementation of ICD-10 will require considerable business and system changes throughout the healthcare industry. The ICD-10 conversion will significantly impact all segments of the health care industry due to:

  • Increased specificity and numbers of codes, going from approximately 3,800 ICD-9 procedure codes to 87,000 procedure codes
  • Expansion of diagnosis codes from 13,000 (ICD-9) to 68,000 (ICD-10)
  • Changing from five-digit numeric codes (except for E and V) to seven-character alphanumeric codes
  • Codes include designation of laterality (left and right)
  • Chapters, categories, and titles have been restructured
  • Combination diagnosis and symptom codes have been created

Benefits

The benefits of the ICD-10 conversion include:

  • Accurate payments for new procedures not currently covered by ICD-9 coding
  • Fewer rejected claims due to more specific, non-ambiguous code designations
  • Improved patient disease management
  • Synchronization of disease monitoring and reporting worldwide

Additional Resources

American Medical Association (AMA)
AMA ICD-10 Project Planning Template
AMA ICD-10 Checklist

Centers for Medicare & Medicaid Services (CMS)

American Health Information Management Association (AHIMA) - Tools for the ICD-10 implementation

American Academy of Professional Coders (AAPC) - ICD-10 implementation and training information

Healthcare Information and Management Systems Society (HIMSS) - This ICD-10 Playbook page contains information about transitioning to ICD-10.

Preparedness Survey Results

ICD-10 Provider Preparedness Survey results for 2012
ICD-10 Provider Preparedness Survey results for 2011

Training

American Health Information Management Association (AHIMA)
American Academy of Professional Coders (AAPC)
Health Care Compliance Strategies (HCCS)
ICD-10 Coders Academy

Testing

Please contact your Provider Relations Consultant if you have any questions related to ICD-10 testing.