Claims

You’ll need to fill out a claim form.

You must file claims within 1 year 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 120 days from the paid date to resubmit a revised version of a processed claim. 

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 West 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 West Virginia

PO Box 982965

El Paso, TX 79998-2965

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

You can resubmit a claim through Availity or by mail. If you resubmit by mail, you’ll need to include these documents:

• 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

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

In-network providers have the right to appeal the result of a decision. You’ll want to file your appeal in writing within 90 calendar days of the Notice of Action. 

You'll get a final determination letter with the appeal decision, rationale and date of the decision. We usually resolve provider appeals within 30 calendar days.

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. 

Before filing an appeal: You should contact Claims Inquiry/Claims Research (CICR) as the first step to clarify any denials or other actions relevant to the claim. In many cases, claim denials are the result of inaccurate filing practices, so be sure to call beforehand to check on claim information. Just call 1-888-348-2922 (TTY: 711). Or check your provider manual for more information. 

Learn more about claim appeals

Online
 

If you submit online, you’ll need to go through Availity. 

By mail

If you submit by mail, 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

Be aware that we:

• Process and decide claims within 30 days of receipt. This includes processing clean payments for professional and institutional claim submissions
• Process and decide claim reconsiderations within 120 days of the resolution date on the original (clean) claim’s EOB
• Identify a Coordination of Benefit (COB) resubmission as a claim previously denied for other insurance info, or originally paid as primary without coordination of benefits
• Process and decide COB claim reconsiderations within 120 days from the disposition date on the primary carrier’s EOB or response letter

EFT makes it possible for us to deposit electronic payments directly into your bank account. Some benefits of setting up an EFT include:
 

• Improved payment consistency 

• Fast, accurate and secure transactions

ERA is an electronic file that contains claim payment and remittance info sent to your office. The benefits of an ERA include:
 

• Reduced manual posting of claim payment info, which saves you time and money, while improving efficiency  

• No need for paper Explanation of Benefits (EOB) statements

EERS offers payees multiple ways to set up EFT and ERA in order to receive transactions from multiple payers. If a provider’s tax identification number (TIN) is active in multiple states, a single registration will auto-enroll the payee for multiple payers. You can also complete registration using a national provider identifier (NPI) for payment across multiple accounts.

ECHO Health processes and distributes claims payments to providers. To enroll in EERS, visit the Aetna Better Health ECHO portal. You can manage electronic funds transfer (EFT) and electronic remittance advice (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.