Provider News & Info

Spring 2024

Update: New claims payment system & what we're doing to make things better

We continue to work through the challenges of implementing a new claims payment system. Currently, only 30% of our membership is on the new system. We’ll add more members to the new system this year; however, most of our members won’t be migrated until July 2025.

We’re happy to report that the new system is automatically paying over 80 percent of claims. Despite this progress, we’re still working to improve various data interfaces and processes to accommodate the anticipated increase in members in 2025.

In response to feedback about phone hold times, we’re taking steps to reduce wait times. We're hiring additional part-time employees to help answer phones, particularly during peak hours. Note that hold times are typically shorter on Mondays, Fridays, and later in the day. However, the fastest way to get a response is via the secure Message Center when you login to the New Provider Portal. When calling us, please select the correct queue within the provider phone tree to avoid longer wait times. Choosing the right option ensures faster assistance.

Thank you for your patience and understanding as we work to provide better service to everyone.

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Tips to submit corrected/voided claims to prevent duplication/denials

Understanding Corrected and Voided Claims

A corrected or replacement claim is a resubmission of a previously processed claim with changes or corrections to charges, clinical or procedure codes, dates of service, or member information. Note: A corrected claim is not an inquiry or appeal.
A voided or canceled claim is used to eliminate a previously submitted claim entirely due to errors or other issues.

Resubmitting Institutional Claims

UB-04 Paper Claim Form

Use bill types ending in "XX7" for corrected claims.
Use bill types ending in "XX8" for voided claims.
The original claim number is required in field 64.

UB-04 Electronic Submission

Loop 2300 required.
CLM05-3 (Claim Frequency Type Code) must be entered as 7 for Replacement or 8 for void.
Include REF segment with the original claim number from the remittance advice, REF01 = “F8”, REF02 = Original claim number.

Note: Resubmission of a corrected claim must include the entire episode of care, not just a single claim line. Upon resubmission, the original claim will be recouped, and the corrected XX7 will replace the initial episode.

Resubmitting Professional Claims

CMS 1500 Paper Claim Form

Corrected Claims: Complete box 22 with resubmission code 7 in the left and original claim number in the right.
Voided Claims: Complete box 22 with resubmission code 8 in the left and original claim number in the right.

HCFA 1500 Electronic Claim

Loop 2300 required.
CLM05-3 (Claim Frequency Type Code) must be entered as 7 for Replacement or 8 for void.
Include REF segment with the original claim number from the remittance advice, REF01 = “F8”, REF02 = Original claim number.

If you have questions, please send us a message via the Message Center in the New Provider Portal.

New PEHP preauthorization requirements and policy changes

We want to keep you informed of new preauthorization (PA) requirements* and new policy changes on important medical procedures. Please familiarize yourself with these new PA requirements to provide the best care for your patients without unnecessary delays.

Effective April 1, 2024

Preauthorization required for maternity care associated with the following CPT Codes: 59000, 59001, 59012, 59015.
PEHP will no longer cover Implantable Peripheral Nerve Stimulators. This change in coverage affects the following CPT Codes: 64555, 64568, 64575, 64585, 64590, 64595.
Policy updates to infertility services related to Assisted Reproductive Technology. New policy defines benefit information, eligibility, and qualifying procedures.

You can view all PEHP clinical policies, authorization forms, and master policies via the New Provider Portal. Here’s how:

Log in to the New Provider Portal and choose Office Management --> Communications Archive from menu on top.
Next, choose a provider from your office.
Then, choose the policy or authorization document from the Document Type drop-down menu.

To obtain PA, please call PEHP at 801-366-7755.

See Medical PA Requirements

*Please note that not all affected codes may be listed, and codes are subject to change at PEHP's discretion.

Free insulin for all PEHP members in 2024

Did you know? PEHP members can get Insulin Lispro (generic Humalog) at No Cost. This means your patients with diabetes can receive their insulin without any copay, making it more accessible for them to manage their condition.

If you have patients with diabetes who need insulin, you can help them reduce costs when you prescribe Insulin Lispro (generic Humalog).

If you have any questions, don't hesitate to reach out to our pharmacy department at 801-366-7551.

How to update provider demographic information

To update your name, address, phone number, or other demographic information please complete the Provider Account Information Form. Note: Do not fill out this form if you work under a new TIN. NPI number required on all changes.

How to add/remove a single provider from existing group contract

Please complete the Add/Remove Provider - Current Group Contract form and return to PEHP via email: providersubmissions@pehp.org or the Message Center in the New Provider Portal. Note: NPI number required on all changes.

How to add/remove multiple providers from existing group contract via roster submission

Please complete the roster form and return to PEHP via email: providersubmissions@pehp.org or the Message Center in the New Provider Portal. Note: NPI number required on all changes.

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Impacted by the Change Healthcare cyberattack?

If your office has been affected by the recent cyberattack on Change Healthcare, we understand the challenges you may be facing in submitting claims. If you've chosen to switch to a new clearinghouse or billing service, please contact our EDI department at edi.helpdesk@pehp.org with your new Trading Partner Number. This will ensure a smooth transition and uninterrupted claims processing and payment.

How to view remittance advice/EOP for your claims in the New Provider Portal

To view a remittance advice/EOP for a claim submitted in the new system, log in to the New ProviderPortal and choose Office Management-->Communications Archive from menu on top. Next, choose a provider from your office and “EOP” from the Document Type drop-down menu.

Important! Make sure to select the provider entry with the Supplier number “S000xxx” (not the Supplier Location or Practitioner number).

If you don’t see a remittance advice/EOP for a past claim, please send us a message via the Message Center in the New Provider Portal.

How to check benefits and eligibility in the New Provider Portal

The process to check patient benefit eligibility with PEHP is simple. Here’s how.

Login to the New Provider Portal.
From the Office Management menu, go to Eligibility.
On the Eligibility Search page, enter the Patient’s Name, Subscriber ID, or Social Security Number, along with the patient’s Date of Birth. Both fields are required.
Once the Eligibility Search Results are displayed, click on the Patient’s name.
Next, search for a provider if you have more than 50 providers in your office. If you have less than 50 providers in your office, select a provider from the drop-down. Then choose Service Type.
The system will return Benefits and Eligibility based on the Service Type selected.

How to contact us

Claims, provider portal, and other customer service items

If you need to report a new issue or have any concerns, the best way to contact us is via the secure Message Center in the New Provider Portal. When calling us (801-366-7555), please select the correct queue within the provider phone tree to avoid longer wait times. Choosing the right option ensures faster assistance.

PEHP Provider Contracts

If you have questions about your contract with PEHP, please contact the following:

Todd Sprouse, Director of Provider Contracting

801-803-0143

todd.sprouse@pehp.org

Mike Corrigan, Senior Provider Contracting Manager

801-597-5682

mike.corrigan@pehp.org

Cammie Keim, Provider Contracting Manager

801-419-3699

cammie.keim@pehp.org