Providers > Claims Information

Filing Procedures

Covered Participants are never required to file a claim when Covered Services are provided by Preferred (In-Network) Providers. When they receive care from a Non-Preferred (Out-of-Network) Qualified Provider, they will need to file a claim or have their provider file a claim for the covered participant to receive reimbursement. For out-of-network claims please contact the Manager of Network and Provider Relations at (215) 746-7906 or via email.

In some cases, at the discretion of the Carrier, arrangements may be made to have payments made directly to the provider such as in the case of a facility or other hospital setting.

Preferred (In-Network) Providers of PENN Behavioral Health must notify University of Pennsylvania and University of Pennsylvania Health System Covered Participants of their In-Network status prior to billing so Covered Persons will know not to submit claims.

Preferred (In-Network) Providers must also notify PENN Behavioral Health for a pre-claims benefit determination to assure their eligibility and benefit coverage. Failure to notify PENN Behavioral Health prior to treatment may result in forfeiture of payment or delay in claim processing.

Preferred (In-Network) Providers are expected to submit "clean claims" for prompt processing and payment. A "clean claim" must contain no defect or impropriety, including a lack of any required substantiating documentation, HIPAA compliant coding or other particular circumstance requiring special treatment that prevents timely payment from being made.

If at any time PENN Behavioral Health requires additional information from any party external to PENN Behavioral Health, the claim is no longer considered a "clean claim" and may be referred as an "unclean" or contested claim.

It is the Provider's responsibility to:

  • Collect applicable co-payments from Covered Persons and submit "clean claims" for the services provided;
  • Submit "clean claims" for non-facility based professional services on an accurately completed paper CMS-1500 claim form (formerly HCFA-1500);
  • Submit "clean claims" for facility based professional services on a accurately completed paper UB-92 claim form for facility based services and programs;
  • Submit "clean claims" for professional outpatient services provided by the staff of a facility which are not part of a structured outpatient program, or when a facility per diem is exclusive of professional charges on an accurately completed paper CMS-1500 claim form (formally HCFA-1500)
  • Required information submitted includes:
    • Name of covered person
    • Name of patient
    • Address
    • Phone Numbers,
    • Date of Birth
    • Employee ID # and Plan Name
    • Provider's (Qualified Professional or Facility Provider) Name (with degree),
    • Provider’s address
    • Provider’s phone number,
    • Dates of service
    • Diagnosis (by listed codes and/or description) and services performed (by codes or rates) with associated itemized charges
    • Itemized bills (based on negotiated rates for services)
  • Use only HIPAA compliant service codes
  • Submit all claims by mail or "dedicated confidential fax" and not e-mail or phone
  • Submit all claims in compliance with regulatory and/or contractually required timely filing standards; and
  • Respond to requests for additional information or other corrective action in a timely manner (within 45 days).

It is PENN Behavioral Health's responsibility to:

  • Send providers authorization letters when services are authorized which includes:
    • Telephone numbers for clinical and claims questions
    • An identification number for the covered person
    • The authorized services
    • The number of units and time period for the authorization
    • An authorization number for the authorized services; and
    • The payor and address to which the claims must be sent
  • Use only HIPAA compliant service codes
  • Review all claims in a timely manner to determine:
    • Benefit eligibility of covered person
    • Benefit coverage of covered person
    • Benefit adjustment (exchange, co-insurance, or co-benefit) if needed
    • Claim completeness (cleanliness); and
    • Correct provider information and updated credentialing
    • The payor and address to which the claims must be sent
  • Give providers appropriate notice regarding corrective action or missing information if a claim is determined to be "unclean" or contested. If PENN Behavioral Health does not receive the information requested within 45 days, the claim will be adjudicated based on the information available, which may result in a denial for insufficient information, subject to applicable state and federal law.
  • Send providers an Explanation of Payment (EOP) and other notification for each claim submitted (including procedures for filing an appeal for adverse claim determinations)

When Claims Should Be Filed

Claims should be filed with the Claims Department within the 60 days of the date charges for the services were incurred. Benefits are based on the Plan's provisions at the time the charges were incurred.

Claims filed later than that date may be declined or reduced unless:
(a) it's not reasonably possible to submit the claim in that time; and (b) the claim is submitted by the end of the 90 day deadline from the time when the claim was incurred.

If it is not possible to file the claim within the 60-day period, the provider must submit in writing the reason for the delinquent claim, but in no event will the Plan be required to accept the claim submitted more than 90 days after the end of the Benefit Period in which the Covered Services are rendered.

Claims guidelines

Conversion of benefits (PDF)
Level of Care Guidelines (PDF)
Provider Guidelines (PDF)

Additional Claims Information

Providers who have questions regarding claims can call PENN Behavioral Health Member Services (Access Services Department) at (1-888-321-4433) and the full process for filing a claim will be described.

The provider must include the above pertinent information and return it with any itemized bills to:

PENN Behavioral Health
Claims Department
3535 Market Street, 4th Floor
Philadelphia, PA 19104

Please submit claims no later than 60 days after the completion of the Covered Services. The claim should include the date and information required by the Carrier to determine benefits.

The Claims Administrator will determine if enough information has been submitted to enable proper consideration of the claim. If not, more information may be requested from the claimant. The Plan reserves the right to have a Plan Participant seek a second medical opinion.