Billing and Claims Payment

Read about:

Billing and Claims Payment

Where to Send Claims

Mail manual claims to this address:

CHP Claims
P.O. Box 269002
Plano, TX 75026-9002

Electronic Claims Submission

Community Health Plan uses Availity as the primary clearinghouse for claims. The clearinghouse’s use of specific edits ensures the accuracy of all claims forwarded.

The Availity clearinghouse offers the convenience of:

  • 24 hour availability
  • Detailed online submission and error reports

Please contact your software vendor to begin the process of electronic billing.

Newborn Claims for Healthy Options, State Children’s Health Insurance Program, Basic Health, and Basic Health Plus

Providers should bill for newborn care using the mother's Community Health Plan ID number until the newborn is assigned his or her own Plan ID number.

Claims Documents:

Completed consent forms and 30-day wait period after signature are required for payment of Healthy Options, CHIP, Basic Health Plus, S-Med, and Disability Lifeline claims.

Coordination of Benefits

Coordination of benefits (COB) becomes necessary when there is more than one source of payment for health services. The payment for such services is coordinated to assure that the insurer who has primary responsibility for coverage pays for the services.

At the time of registration, patients should be asked if they have other insurance coverage. If there is another possible source of insurance identified, this information should be included on the claim form.

Community Health Plan will coordinate benefit payments with any other group plans, Medicaid plan, or Medicare plan that covers the enrollee. Benefit payments will not be coordinated with any individual coverage the enrollee has purchased.

To be processed if an enrollee is covered by more than one health insurance plan, claims must be submitted to Community Health Plan with an Explanation of Benefits statement from the other carrier.

The health plan that is to provide benefits first will do so for all the expenses allowed under its coverage. The other plan will then provide benefits for the remaining allowed expenses.

When Medicare or another governmental program of health care coverage is one of the plans, federal law determines which plan provides benefits first:

  • Healthy Options is always the secondary payer.
  • Basic Health is always the secondary payer, except when there is dual coverage with Healthy Options or CHAMPUS.

For Medicare, Community Health Plan follows Medicare as Secondary Payer rules. Otherwise, the following rules determine which plan provides benefits first:

  1. When both plans coordinate benefits, the plan covering the person as a subscriber provides benefits first.
  2. Dependent children are covered first under the plan of the parent whose birthday is earlier in the calendar year. If the parents are divorced or separated, the following rules determine which plan pays first:
    1. Plan of the parent with custody.
    2. Plan of the spouse of the parent with custody.
    3. Plan of the parent without custody.
    4. Plan of the spouse of the parent without custody.
      If there is a court decree that establishes responsibility for the child’s health care, the plan of the parent with that responsibility provides benefits first.
  3. If none of these rules establishes which plan provides benefits first:
    1. The plan that has covered the enrollee the longest time provides benefits first.
    2. All other plans provide benefits first if the person is a retiree, a laid-off employee, or a dependent of a person who is retired or laid off, if the other plans include this rule.
  4. When none of the above rules establishes the order of benefits, then the plan that has covered a subscriber for the longer period of time will provide benefits first.

Third Party Liability (Subrogation/Reimbursement)

Community Health Plan benefits are available to an enrollee who is injured or becomes ill because of a third party's action or omission. Community Health Plan has subrogation rights and other rights to recovery against any third party liable for the illness or injury. This means Community Health Plan:

  1. Is entitled to reimbursement from recoveries by the enrollee from the liable third party after the enrollee is fully compensated for his or her loss, and
  2. Has the right to pursue claims for damages from the party liable for the injury or illness. Community Health Plan's rights extend to the value of benefits paid by the plan for such an injury or illness.

As a condition of receiving benefits for such an illness or injury, the enrollee and his or her representatives are responsible for cooperating fully with Community Health Plan in recovering the amounts it has paid including, but not limited to:

  • Providing information to Community Health Plan concerning the facts of the illness or injury and the identity and address of the third party or parties who may be liable for the illness or injury, their liability insurers, and their attorneys.
  • Providing reasonable advance notice to Community Health Plan of any trial or other hearing, or any intended settlement, of a claim against any such third party.
  • Repaying Community Health Plan from the proceeds of any recovery from or on behalf of any such third party.

Provider Obligations in Third Party Liability

A provider is responsible for notifying Community Health Plan when he or she becomes aware that an enrollee has a right to reimbursement from a third party and to assist in arranging for assignment of such right to Community Health Plan for collection.

The following information, to the extent that the provider is aware, should be reported to Community Health Plan:

  • Facts of the enrollee's condition or injury.
  • Any changes in the enrollee's condition or injury.
  • Name of any person responsible for the enrollee's condition or injury and that person's insurance carrier.