You’ll need to fill out a claim form.

You must file claims within 365 days from the date you provided services, unless there’s a contractual exception. For inpatient claims, the date of service refers to the member’s discharge date. You have 365 days from the paid date to resubmit a revised version of a processed claim. 

All claims must be submitted with this information:

• Member’s name, date of birth and Medicaid ID number
• Type of service
• Date and location of service
• Billing and/or rendering provider taxonomy codes that are consistent with the provider’s registered specialty with DMAS
  NPI (not required for atypical providers)
• Practice address
• Billing address

For more information, visit Chapter 13 of our provider manual.

Make sure you are enrolled as a provider through the Virginia MES Provider Portal. 

Online

Availity is our provider portal, which provides functionality for the management of patients, claims, authorizations and referrals. To submit claims online via Availity, choose the button labeled “Medicaid Claim Submission – Office Ally.” This link will take you directly to the Office Ally website where you can submit claims using their online claim entry feature or by uploading a claim file.

Providers must have an Office Ally account to submit claims online. Submission of your Aetna Better Health of Virginia claims using Office Ally is free of charge. The status of claims submitted online should be managed through your Office Ally Account.

By mail

You can also mail hard copy claims or resubmissions to:

Aetna Better Health® of Virginia

P.O. Box 982974 

El Paso, TX 79998-2974

Mark resubmitted claims clearly with “resubmission” to avoid denial as a duplicate. 

CMS-1500 sample (PDF)

To see a sample of a UB-04 form, check your provider manual (PDF).

You can resubmit a claim through Availity. Choose the button “Medicaid Claim Submission – Office Ally.” Or resubmit a claim by mail. If you resubmit by mail, you’ll need to include these documents:

• Claim resubmission/appeal request form (PDF)
• An updated copy of the claim — all lines must be rebilled
• A copy of the original claim (reprint or copy is acceptable)
• A copy of the remittance advice on which we denied or incorrectly paid the claim
• A brief note describing the requested correction
• Any other required documents

Use the claim resubmission/appeal request form (PDF) for claim issues concerning:

• Nonclinical denials
• Missing information
• A correction
• Rate reimbursement disagreements

Use the provider claim resubmission/appeal request form for these reasons: 

• Itemized bill: Mark the top of the claim “CLAIM FOR RESUBMISSION.”
  
  
  • We must receive it within 35 days after receipt of the notification
  • Break out all claims associated with an itemized bill per rev code so we can verify charges billed on the UB match the charges billed on the itemized bill. Attach I-Bill broken out by rev code with sub-totals.
• Duplicate claim: Mark the top of the claim “CLAIM FOR RESUBMISSION.”
  
  
  • Review request for a claim whose original reason for denial was “duplicate.”
  • Provide documentation about why the claim or service is not a duplicate such as medical records showing two services you performed.
• Proof of timely filing: Mark the top of the claim “CLAIM FOR RESUBMISSION.”
  
  
  • For electronically submitted claims, provide the second level of acceptance report.
  • Refer to Proof of Timely Filing Requirements in the Provider Manual.
• Coordination of benefits: Mark the top of the claim “CLAIM FOR RESUBMISSION.”
  • We must receive it within 90 days after final determination.
  • Attach EOB or letter from primary carrier.
• Claim/coding edit Mark the top of the claim “CLAIM FOR RESUBMISSION.”
  
  
  • We use two claims edit applications: Claim Check and Cotiviti. 
  • Refer to the Provider Manual for details.
• Corrected claim: Mark the top of the claim “CORRECTED CLAIM FOR RESUBMISSION.”
  
  
  • We must receive it within 365 days of the date of service or discharge date. 
  • Newly added modifier
  • Code changes
  • Any change to the original claim

To resubmit a claim with missing information or a correction, mail claim and all supporting documentation appropriately labeled to the address on the form. 

Provider claim resubmissions do not include pre-service denials based on not meeting medical necessity. We process pre-service denials as member appeals, and these are subject to member policies and timeframes.

Both in-network and out-of-network providers have the right to appeal the result of a decision. You’ll want to file your appeal in writing within 60 calendar days of the reconsideration response (date of EOB). 

You'll get a final determination letter with the appeal decision, rationale and date of the decision. We’ll make reasonable efforts to resolve this request within 30 calendar days of receipt. 

If the appeal decision isn’t in your favor, you can’t “balance bill” the member for services or payment that we denied for coverage. 

You can file an appeal:

By phone

Just call us at 1-800-279-1878 (TTY: 711) 

By mail

You can send your appeal to:

Aetna Better Health of Virginia

PO Box 81040

5801 Postal Road

Cleveland, OH 44181

By fax

Fax your appeal to 1-866-669-2459.

By email

Email us your appeal.

Claim appeals for claim denials and payments not related to resubmission

Use the claim resubmission/appeal request form (PDF) for claim appeals on denials and payment amounts that aren’t related to a resubmission. 

Your request for appeal should include the form along with medical records to support your request. Do not submit the member’s entire medical record. Submit the medical records relevant to your request and tell us which pages support your request.

Learn more about claim appeals

A claim reconsideration is a request that we previously received and processed as a clean claim. It’s a review of a claim that a provider believes was paid incorrectly or denied due to processing errors.

When you send a reconsideration, be sure to include:

• A claim form for each reconsideration
• A copy of the remit/Explanation of Benefits (EOB) page for each resubmitted claim, with a brief note about each claim you’re resubmitting
• Any information that the health plan previously requested

You can file a claim reconsideration by mail:

Mail your claim resubmission/appeal request form (PDF) and all supporting documents to:

Aetna Better Health of Virginia

Attn: Reconsiderations

P.O. Box 982974 

El Paso, TX 79998-2974

ECHO Health processes and distributes claims payments to providers. To enroll in EERS, visit the Aetna Better Health ECHO portal. You can manage EFT and ERA enrollments with multiple payers on a single platform.

Sign up for EFT

To sign up for EFT, you’ll need to provide an ECHO payment draft number and payment amount for security reasons as part of the enrollment authentication. Find the ECHO draft number on all provider Explanation of Provider Payments (EPP), typically above your first claim on the EPP. Haven’t received a payment from ECHO before? You’ll receive a paper check with a draft number you can use to register after receiving your first payment.

Update your payment or ERA distribution preferences

You can update your preferences on the dedicated Aetna Better Health ECHO portal. 

Use our portal to avoid fees

Fees apply when you choose to enroll in ECHO’s ACH all payer program. Be sure to use the Aetna Better Health ECHO portal for no-fee processing. You can confirm you’re on our portal when you see “Aetna Better Health” at the top left of the page.

Be aware — you may see a 48-hour delay between the time you receive a payment, and an ERA is available.

• ECHO companion document (PDF)
• ECHO enrollment form (PDF)
• ECHO payments innovation for health plans (PDF)
• ECHO portal guide (PDF)
• ECHO frequently asked questions from providers (PDF)

• Office Ally forms and manuals
• Office Ally online claim entry - professional (HCFA) claims (PDF)
• Office Ally online claim entry – institutional (UB) claims (PDF)

How much claim history is available online?

Three years, depending on the plan.

What Medicaid plan information am I able to see?

Claim Inquiry information includes claim summary, history and detail, just as it appears for commercial plans. Member Eligibility information includes coverage history, PCP (primary care provider) history and COB (coordination of benefit) details, if available. Remittance advices are available. However, benefit information is not available for Medicaid members.

How are offsets and backouts shown on the claim status?

Backout claims (claims that have a negative balance) are associated with a specific claim and are only available by clicking or searching on the original claim associated with the backout. Claim Detail gives you the option to see the original claim, backout claim and/or replacement claim. The claim type is identified at the top of the claim.

What is the Patient Control Number?

The Patient Control Number is the medical record number we receive from the provider associated with the claim.

I currently see "Unpaid Claims" in addition to other statuses. Is this OK?

"Unpaid Claims" isn’t a claims status. It’s a search option which shows all claims that do not yet have a check or EFT payment associated with it. Keep in mind that an approved status may eventually get denied or pended; it’s not a guarantee of payment.

Do claims include the rejected claims from our clearinghouse or where they are rejected from?

No, you won’t be able to see claims rejected at the clearinghouse since we don’t receive them. The rejected claims you can see online are ones that are rejected by us, after they passed through the clearinghouse. If you submitted your claim directly to us, without going through a clearinghouse, then they’ll all appear. An example of a rejection is “patient not found.”

Can I submit claims directly through the Provider Portal?

Claims submission through the Provider Portal will be available in the future, but not right now.   

Why do some claims allow you to view the Remittance Advice and not others?

It depends on who the claim was paid to. If you’re viewing a claim under a provider ID that didn’t receive payment for that claim, then the remittance advice link won’t appear with that claim. To view the remittance advice, look up the remittance advice under the appropriate provider ID it was paid to. You can access remit data from January 11, 2024 to current with the Availity Remit Viewer.

Can claim adjustments be requested online?

Yes. This service allows a provider to request that the plan take another look at a claim based on additional information, including attachments that can be sent through the Provider Portal. However, it’s not a formal appeal. Check the claim resubmission/appeal request form (PDF).

I submitted a claim to the health plan. It was paid, but I cannot find it now. What do I do?

We internally route claims to the correct payer, even if the claim was submitted to the incorrect health plan. If you submitted the claim to the incorrect payer ID and it can’t be found, you should check under another Aetna Better Health plan you do business with. Also, review your remittance advice for any information on the re-routed claim.

Where do I mail my paper claims?

You can mail your paper claims to:

Aetna Better Health of Virginia 

ATTN: Claims Department 

PO Box 982974 El Paso, TX 79998-2974

RC Claim Assist from RJ Health

This online resource helps improve the process for submitting drug-related medical claims. Using a self-service platform, providers can easily convert HCPCS/CPT (Healthcare Common Procedure Coding System/Current Procedural Terminology) drug code units to NDC drug code units. 

RC Claim Assist helps providers and the overall claims process by: 

• Providing a broad crosswalk of HCPCS/CPT drug codes, product names and NDCs
• Reducing the number of resubmissions for claims payment
• Offering complete drug information on package size billable units
• Aligning providers and payers on managing medically covered pharmaceuticals

How to get started

Visit the RC Claim Assist website.

• Register to complete a brief registration process.
• Enter your NPI (National Provider Identifier).
• Enter your first and last name.
• Create your password.

Once you’ve completed registration, you can log in and start using the services. 

What are the billing requirements for NDC?

You can find these details in your provider manual (PDF).

What if an NDC is no longer active?

When billing with NDCs on claims, you’ll want to ensure that the NDC used is valid for the date of service. This is because NDCs can expire or change. An NDC’s inactive status is determined based on a drug’s market availability in nationally recognized drug information databases.

Additionally, an NDC is considered no longer in use two years after its inactive date. We recommend that you do a routine check of records or automated systems where NDCs may be stored in your office for billing purposes. To help ensure that correct reimbursement is applied, the 11-digit NDC on your claim should correspond to the active NDC on the medication’s outer packaging. Inactive products will continue to be reimbursed until they are no longer in use.

Questions about RC Claim Assist?

You can email RJ Health directly. For questions on a specific claims issue, just contact us. 

Centers for Medicare & Medicaid Services (CMS) ICD-10 resources

Conversion tool for Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to ICD-10 (PDF)