Claims and Billing
Filing claims is fast and easy for Keystone First providers. Here you can find the tools and resources you need to help manage your submission of claims and receipt of payments. You may also refer to our Claims Filing Instructions (PDF) for helpful information.
Timely filing limits
- Initial claims: 180 from date of service.
- Resubmissions and corrections: 365 from date of service.
- Claims with explanation of benefits (EOBs) from primary insurers, including Medicare, must be submitted within 60 days of the date on the primary insurer’s EOB. (When submitting an EOB with a claim, the dates and the dollar amounts must match to avoid rejection of the claim.)
Submit claims through electronic data interchange (EDI) for faster, more efficient claims processing and payment. Keystone First's EDI payer ID number is 23284.
Electronic claims may be submitted via:
Availity
- Providers or clearinghouses not currently using Availity to submit claims must register with Availity.
- Providers who are currently registered with Availity for another payer, or using another clearinghouse, must request to have electronic claims for Keystone First routed to Availity.
- For registration process assistance, submit the Provider Inquiry form at the bottom of the Availity webpage or contact Availity Client Services at 1-800-AVAILITY (282-4548). Assistance is available Monday through Friday from 8 a.m. to 8 p.m. ET.
Optum/Change Healthcare
- Providers who have a software vendor or use another clearinghouse to submit claims to Optum/Change Healthcare will need to consult with their vendor/clearinghouse to see if there have been changes in their process for claims submission.
- For questions, contact Optum/Change Healthcare’s call center at: 1-800-527-8133, Monday through Friday from 7 a.m. to 5:30 p.m. CT.
Providers may submit manual/direct entry claims (at no cost) via:
Optum/Change Healthcare ConnectCenter™
Access the portal via the Claims submission link in the NaviNet provider portal or via ConnectCenter to complete your provider registration.
- Note: this URL is specific to new provider registration only.
- For detailed instructions on the registration process, see the Provider Sign-up and User Management guide in the Claim resources section of this page.
- Follow the instructions on the login page to reset your password and to set up the required multi-factor authentication.
- For more information on available functionality, please review the release notes in the Product News section after signing into the ConnectCenter portal.
- Optum/Change Healthcare provides other helpful user guides to assist providers with navigating the ConnectCenter portal. These guides are also available in the Claim resources section of this page.
PCH Global
Visit PCH Global to enroll for claims submission through PCH Global,
- Click the Sign-Up link in the upper right-hand corner.
- Complete the registration process and log into your account. You will be asked how you heard about PCH Global; select Payer, then AmeriHealth. Access your profile by clicking on Manage User and then My Profile. You will need to complete all the profile information. When you go to the Subscription Details screen, select the More option on the right-hand side to see how to enter the promo code Exela-EDI.
- When you are ready to submit claims, use the following information to search for our payer information:
- Payer name: Keystone
- P.O. Box: 7115
For a detailed walk-through of the registration process, refer to the PCH Global Registration manual (PDF), found on the PCH Global website in the Resources Menu.
Send paper claims to:
Keystone First
Claims Processing Department
P.O. Box 7115
London, Kentucky 40742
Keystone First is accepting ANSI 5010 ASC X12 275 claim attachment transactions (unsolicited). Please contact your Practice Management System Vendor or EDI clearinghouse to inform them that you wish to initiate electronic 275 claim attachment transaction submissions for payer ID 23284 via:
Availity
There are two ways 275 claim attachments can be submitted:
- Batch — You may either connect to Availity directly or submit via your EDI clearing house.
- Portal — Individual providers may also register online to submit attachments.
After logging in, providers registered with Availity may access the Attachments - Training Demo for detailed instructions on the submission process or refer to the Availity Claims Attachment Quick Reference guide located under Claim Resources at the bottom of the page.
Optum/Change Healthcare
There are two ways that 275 attachments can be submitted:
- Batch — You may either connect to Optum/Change Healthcare directly or submit via your EDI clearing house.
- API via JSON — You may submit an attachment for a single claim.
General guidelines
- A maximum of 10 attachments are allowed per submission. Each attachment cannot exceed 10 megabytes (MB) and total file size cannot exceed 100MB.
- The acceptable supported formats are pdf, tif, tiff, jpeg, jpg, png, docx, rtf, doc, and txt.
- The 275 attachments must be submitted prior to the 837. After successfully submitting a 275 attachment, an Attachment Control Number will generate. The Attachment Control Number must be submitted in the 837 transactions as follows:
- CMS 1500
- Field Number 19
- Loop 2300
- PWK segment
- UB-04
- Field Number 80
- Loop 2300
- PWK01 segment
- CMS 1500
In addition to the attachment control number, the following 275 claim attachment transaction report codes must be used when submitting an attachment. Enter the applicable code in field number 19 of the CMS 1500 or field number 80 of the UB04, as documented in the Claims Filing Instructions.
| Attachment type
| Claim assignment attachment report code |
|---|---|
| Itemized bill
| 03
|
| Medical records for HAC review
| M1
|
| Single case agreement (SCA)/LOA
| 04
|
| Advanced beneficiary notice (ABN)
| 05
|
| Consent form
| CK
|
| Manufacturer suggested retail price/Invoice
| 06
|
| Electric breast pump request form
| 07
|
| CME checklist consent forms (child medical eval.)
| 08
|
| EOBs for 275 attachments should only be used for non-covered or exhausted benefit letter
| EB
|
| Certification of the decision to terminate pregnancy
| CT
|
| Ambulance trip notes/Run sheet
| AM
|
To inquire about claim status, sign in to NaviNet and select Claims Status Summary under Administrative Reports. Provider Claim Services can also check the status of up to 5 claims via phone at 1-800-521-6007.
Requests for reconsideration may be submitted through the NaviNet Electronic Claim Inquiry feature.
A provider dispute is a verbal or written expression of dissatisfaction by a plan provider regarding a plan decision that directly impacts the plan provider. Disputes are generally administrative in nature and do not include decisions concerning medical necessity. Disputes may focus on issues concerning the plan services and processes, other health care providers, members, or claims.
For complete information and details please refer to the Keystone First Provider Manual.
An appeal is a written request from a plan provider for the reversal of a denial by the plan, through its Formal Provider Appeals Process.
For complete information and details please refer to the Keystone First Provider Manual.
If a plan provider identifies improper payment or overpayment of claims from Keystone First, the improperly paid or overpaid funds must be returned to the plan within 60 days from the date of discovery of the overpayment. Please include the member’s name and ID, date of service, and claim ID.
For complete information and details please refer to the Keystone First Provider Manual.
Keystone First offers ERAs through ECHO Health, Inc. ECHO is a leading provider of electronic solutions for payments to healthcare providers. ECHO consolidates individual provider and vendor payments into a single compliant format, remits electronic payments and provides an explanation of payment (EOP) details to providers.
To receive ERAs providers, will need to include both the plan payer ID and the ECHO payer ID: 58379. Contact your practice management/hospital information system for instructions on how to receive ERAs from Keystone First under payer ID 23284 and the ECHO payer ID 58379.
All ECHO Health-generated ERAs and EOPs for each transaction will be accessible to download from the ECHO provider portal. If you are a first-time user and need to create a new account, please reference ECHO Health's Provider Payments Portal Quick Reference Guide (PDF) for instructions.
If your practice management/hospital information system is already set up and can accept ERAs from Keystone First, it is important to check that their system includes both the plan and ECHO Health payer IDs.
If you are not receiving any payer ERAs, contact your current practice management/hospital information system vendor to ask if your software can process ERAs. Your software vendor is then responsible for contacting Optum/Change Healthcare to enroll for ERAs under payer ID 23284 and ECHO Health payer ID 58379.
If your software does not support ERAs or you continue to reconcile manually, but would like to start receiving ERAs only, please contact the ECHO Health Enrollment team at 1-888-834-3511.
- Availity
- Optum/Change Healthcare ConnectCenter electronic claims user guides:
- ConnectCenter Overview (PDF)
- Provider Sign-up and User Management (PDF)
- Enrollment Central – Getting Started (PDF)
- Claims – Getting Started (PDF)
- Claim Status – Getting Started (PDF)
- Uploading an 837 Batch Claim File (PDF)
- Create a Claim (Video)
- Eligibility – Getting Started (PDF)
- Keying an Institutional Claim UB-04 (PDF)
- Keying a Professional Claim (PDF)
- Provider Management – Getting Started (PDF)
- Remits – Getting Started (PDF)
Third-party liability (TPL) is when the financial responsibility for all or part of a member's health care expenses rests with an individual entity or program (e.g., Medicare, commercial insurance) other than Keystone First.
Coordination of benefits (COB) is a process that establishes the order of payment when an individual is covered by more than one insurance carrier. Keystone First is always the payer of last resort. This means that all other insurance carriers (the “primary insurers”) must consider the health care provider’s charges before a claim is submitted to Keystone First.
Please refer to the Claims Filing Instructions (PDF) for more specific information, including guidance on submitting TPL claims and COB/secondary claims.
Medicare as a third-party resource
For Medicare services that are covered by Keystone First, we will pay, up to the plan contracted rate, the lesser of:
- The difference between the Keystone First contracted rate and the amount paid by Medicare, or
- The amount of the applicable coinsurance, deductible, and/or copayment.
In any event, the total combined payment made by Medicare and Keystone First will not exceed the Keystone First contracted rate.
Commercial third-party resources
For services that have been rendered by a network provider, Keystone First will pay, up to the plan contracted rate, the lesser of:
- The difference between the Keystone First contracted rate and the amount paid by the primary insurer, or
- The amount of the applicable coinsurance, deductible, and/or copayment.
In any event, the total combined payment made by the primary insurer and Keystone First will not exceed the plan contracted rate.
Prenatal TPL
Keystone First complies with the requirements outlined in the Bipartisan Budget Act of 2018 (Pub. L. 115-123), amended section 1902(a) (25) (E) of the Social Security Act and the Department of Human Services Medical Assistance (MA) Bulletin (01-19-12) (PDF) regarding payment for prenatal care as follows:
If there is a third-party resource, providers are to submit claims to that resource prior to submitting a claim for prenatal services to Keystone First.
Providers must verify whether a member has insurance coverage in addition to Medical Assistance (MA). Providers can verify member eligibility and benefits through any of the following methods:
- NaviNet
- Keystone First eligibility line — 1-800-521-6007
- Pennsylvania Eligibility Verification System (EVS) — 1-800-766-5387
All requirements are outlined in MA Bulletin 01-19-12 (PDF).
Electronic claim payment options
Keystone First works with ECHO Health Inc. (ECHO®), a leading innovator in electronic payment solutions, to offer more electronic payment options to our health care providers. Providers can select the payment method that best suits their accounts receivable workflow.
ECHO Health offers virtual credit cards as an optional payment method. Virtual credit cards are randomly generated, temporary credit card numbers that are either faxed or mailed to providers for claims reimbursement. VCC payments have several advantages for providers:
- No need to enroll or fill out multiple forms in order to receive VCC.
- Personal information is never requested, such as practice bank account information.
- Payments are accessible the day the VCC is received.
Providers not registered to receive payments electronically will receive VCC payments as their default payment method, instead of paper checks. Your office will receive either faxed or mailed VCC payments, each containing a VCC with a number unique to that payment transaction, an instruction page for processing the payment, and a detailed Explanation of Payment/Remittance Advice (EOP/RA).
Normal transaction fees apply based on your merchant acquirer relationship. If you do not wish to receive your claim payments through VCC, you can opt out by contacting ECHO Health at 1-888-492-5579.
Electronic funds transfers allow you to receive your payments directly in the bank account you designate rather than receiving them by VCC or paper check. When you enroll in EFT, you will automatically receive electronic remittance advices (ERAs) for those payments. All generated ERAs and a detailed explanation of payment for each transaction will also be available on the ECHO provider portal.
If you are new to EFT, you will need to enroll with ECHO Health for EFT from Keystone First.
Please note: Payment will appear on your bank statement from PNC Bank and ECHO as “PNC — ECHO.”
Sign up to receive EFT from Keystone First. There is no fee for this service.
Visit the ECHO Health website to sign up to receive EFT from all of your payers that process payments on the ECHO platform. A fee may be required to receive EFT if you select the all payers option.
If you already receive payments from ECHO Health, you may be able to enroll for EFT with Keystone First using your existing account. Please make sure you have an ECHO Health draft number and corresponding payment amount so your enrollment request can be validated.
A draft number is listed as the EPC draft number on ECHO Health's explanation of payments. If you need assistance locating an ECHO payment in order to register, contact ECHO at 1-800-946-4041, Monday through Friday, from 8 a.m. to 6 p.m. ET.
If you have questions on how to enroll in EFT, please see the Keystone First EFT Enrollment Guide (PDF).
Electronic Remittance Advices (ERAs) (often referred to as an 835 file) are also available through ECHO Health. To receive ERAs from Keystone First, it is important to check with your practice management/hospital information system vendor to see if the system includes both the Keystone First payer ID 23284 and the ECHO Health payer ID 58379.
If you are not receiving any payer ERAs, please contact your current practice management or hospital information system vendor to ask if your software can process ERAs. Your software vendor is then responsible for contacting ECHO to enroll you for ERAs under the Keystone First payer ID 23284 and the ECHO Health payer ID 58379.
If your software does not support ERAs or you continue to reconcile manually, and you would like to start receiving ERAs only, please contact the ECHO Health enrollment team at 1-888-834-3511.
If you have additional questions regarding VCC, EFT, or ERAs, please see our FAQ (PDF) or call the ECHO Health support team at 1-888-492-5579.