Coventry Health Care

Basics for Medical Billers

Coventry Health Care, Inc. operates a number of health plans, insurance companies, and worker's compensation service companies in all 50 states. Medical billers are likely to need to submit claims to this company. They provide a web portal to do most of these tasks.

1
Plans Included Under Coventry Health Care

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Coventry Health Care includes the following plan names, as well as others:

Coventry Health Care National Network
First Health Network
Mail Handlers Benefit Plan
Altius
Carelink
Coventry Health Care of Delaware, Florida, Georgia, Iowa, Kansas, Louisiana, Nebraska, Nevada
Coventry Health and Life of Oklahoma, Tennessee
Coventry Missouri
Group Health Plan
HealthAmerica / HealthAssurance
PersonalCare
Southern Health Services
University of Missouri
WellPath
Association Benefit Plan
Foreign Service Benefit Plan
Rural Carriers Benefit Plan
Strategic Outsourcing, Inc
American Postal Workers Union (APWU)
First Health Life & Health Ins. Co.

2
General Information on Coventry Health Care

Refer to Coventry's Contact Grid located in Section 6 of the provider manual.

For Customer Service Issues please check for the Customer Service Phone Number listed on every member ID Card. This Department will be able to help you with the below issues as well as many more.

  • Corrected Claims Issues
  • Itemized Bills
  • Timely Filing
  • Adjudication Issues
  • Requests for EOB and RAs
  • Authorization Requirements
  • Check and Refund Issues
  • Benefit and Member Issues
  • Initial Balance Billing Calls
  • New Provider Inquiries
  • Provider Manual Requests
  • Non Par Demographic changes
  • NPI Questions

For Coventry National Customer Service questions call the telephone number located on the back of the member ID card

3
Eligibility, Benefits and Claim Status

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Eligibility, benefits, and claim status can be verified online in three ways:

  1. Contact the phone number listed on the member's ID card
  2. Through Coventry Health Care's free online provider portal at www.directprovider.com
  3. Through Emdeon Office

4

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Services typically requiring preauthorization include hospital inpatient or observation care, selected outpatient surgery (regardless of type of setting), high cost radiology (such as CT, MRI, IMRT, Bone Density, Whole Body or PET Scans), DME/Prosthetics/Orthotics, Home Care, Pain Management, Rehabilitation (Cardiac/Pulmonary/PT/OT/Speech), Sleep Studies, and services related to Infertility or Transplants.

How to Submit a Precertification Request

Preauthorization requests can be submitted through Coventry Health Care's free online provider portal at www.directprovider.com

For specific questions, contact the preauthorization number listed on the member's ID card.

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5
Billing Information

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Three simple ways:

  1. Electronic claims can be submitted through Coventry Health Care's free online provider portal at www.directprovider.com.
  2. Electronic claims can be submitted through Emdeon's clearinghouse.
  3. Paper claims can be submitted to the Coventry Health Care's claims mailing address listed on the member's ID card.
Secondary claims:
  • Submit electronically
  • Paper claims can be submitted with the primary payer's eob
  • Include adjustment amounts - at both claim level and service line level (if available)
  • Include adjustment reasons - contractual obligation, deductible, coinsurance, etc. Use the codes furnished by the primary payer's remittance
  • Primary payer paid amount - at both claim level and service line level (if available)

6
Timely Filing Requirements

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Timely filing limits are specified in the provider agreement.

7
Corrected Claims

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When making changes to previously paid claims, submit corrected claims electronically. Update the Claim Frequency Code with:
7 = Replacement of a prior claim
8 = Void/cancel of a prior claim

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Submit a corrected claim and Coventry Health Care will recover/recoup the overpayment which will be reported on an ERA with a reversal of the incorrect claim adjudication, followed by the corrected adjudication of the claim.

Refunds due to existing credit balances can be sent to:

Refer to Coventry's Contact Grid located in Section 6 of the provider manual.

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9

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Claims can be reconsidered through Coventry Health Care's free online provider portal at www.directprovider.com or contact the phone number on the member's ID card for information.

Go to the Provider section of the Coventry websites, under Electronic Solutions, to view EDI Documentation and other pertinent information and options that are available to you.

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