Whether you’re filing electronic or paper claims, to avoid having claims delayed, denied, or sent back to you for corrections, you’ll need to:
- Meet filing deadlines
- Submit clean claims
All claims must be received in our office within 95 days of the date of service, or they will be denied. Coordination of Benefit (COB) claims must be submitted within 95 days of the primary payer's Explanation of Benefits (EOP) date.
For paper claims, the claims receipt date is when your claim reaches our mailroom. Claims received after 2 p.m. will be considered received the next business day. Please note that members cannot be billed for claims denied by SWHP for missing filing deadline.
These are claims that we will accept without having to investigate or send back for more information. Clean electronic and paper claims should have:
- Patient's full name
- Patient's date of birth
- Valid SWHP member identification number (11-digit number)
- Complete service level information
- Date of Service
- Industry-standard diagnosis codes
- CMS defined industry-standard place of service codes
- Industry-standard procedure codes (e.g., CPT, HCPCs)
- Charge information and units
- Service provider's name, address, and National Provider Identification (NPI)
- Provider's federal tax identification number (TIN)
- Only one servicing provider per claim
- All claim forms must be typed; no handwritten information or corrections
- All required fields completed
For paper claims, we use an imaging system for claims entry. Follow these guidelines to ensure your claim is processed accurately, and without delay or rejection.
Do not send:
- A fax or a copy of a filled-out form
- A claim that's been torn, taped, or crumpled
- A claim that's been stamped or handwritten on
Do not use:
- Correction fluid or tape
- Ink that is fading, and/or a color other than black
Claims that are rejected for any of the above listed reasons will be returned to you with a letter explaining the reason for the rejection. These non-clean claims are considered never received and must be corrected and resubmitted within the SWHP claims filing deadline for reconsideration.
Watch the following tutorials to learn how to correctly fill in the required fields.
- How to submit a CMS 1500 Claim
- How to submit a UB-04 Claim
We reimburse medically necessary surgical services and other procedures. For more information, see procedure-specific payment policies.