Claims and Billing

AmeriHealth Caritas New Hampshire is accepting ANSI 5010 ASC X12 275 unsolicited claim attachment transactions. The 275 attachments are accepted via Optum/Change Healthcare and Availity. Please contact your Practice Management System Vendor or EDI clearinghouse to inform them that you wish to initiate electronic 275 claim attachment transaction submissions via payer ID 87716.

• 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.

  After logging in, providers registered with Availity may access the Attachments — Training Demo for detailed instructions on the submission process or refer to the reference guide located below in the Claims Resources section.

• Optum/Change Healthcare

  There are two ways 275 claim 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.

  View the Optum Change Healthcare 275 claim attachment transaction video for detailed instructions on this process.

General guidelines

• A maximum of 10 claim attachments are allowed per submission. Each attachment cannot exceed 10 megabytes (MB) and total file size cannot exceed 100 MB.
• The acceptable supported formats are pdf, tif, tiff, jpeg, jpg, png, docx, rtf, doc, and txt.
• The 275 claim attachments must be submitted prior to the 837. After successfully submitting a 275 claim 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

In addition to the Attachment Control Number, the following 275 claim attachment report codes must be reported in field 19 of the CMS 1500 or field number 80 of the UB-04.

Submit claims through electronic data interchange (EDI) for faster, more efficient claims processing and payment.

Submit claims electronically.
AmeriHealth Caritas New Hampshire's EDI payer ID number is 87716.

Send paper claims to:

AmeriHealth Caritas New Hampshire
Attn: Claims Processing Department
P.O. Box 7387
London, KY 40742-7387

Go to NaviNet or call Provider Services at 1‑888‑599‑1479.

If you need to request a change to a decision regarding a claim, please submit your request in writing with the Provider Appeal Form to:

AmeriHealth Caritas New Hampshire
Attn: Claim Appeals
P.O. Box 7388
London, KY 40742-7388

What is or is not included?

• Any drug product, including vaccines for adults, brand name or generic, legend or non-legend, sold or distributed by a drug manufacturer (or labeler) who participates in the Medicaid Drug Rebate Program.
• Excluded from this requirement are drugs dispensed during a hospital inpatient stay and drugs dispensed under the 340B program.

How do I bill?

All claims for outpatient medications must include the National Drug Code (NDC), NDC unit qualifier, and NDC units in addition to the HCPCS codes and HCPCS quantity. This information is required to be collected on all outpatient drug claims in order for the Department of Health and Human Services to bill manufacturers for federal rebates as permitted by the Patient Protection and Affordable Care Act (PPACA).
All claims for outpatient drugs will be validated for the presence of a(n):

1. Valid NDC.
2. NDC that corresponds to the billed HCPCS.
3. Accurate unit of measure for the NDC billed (F2, GR, ML, UN).
4. NDC quantity within appropriate FDA minimum and maximum levels.

Claims not passing all of these validation criteria will be denied.

How can I determine which drugs are included in the Medicaid Rebate Program?

The Medicaid website has detailed Medicaid Drug Rebate Program data.

What is the 5-4-2 format for NDC numbers?

All drug products have an 11-digit NDC. Some of the drug manufacturers do not follow the 5-4-2 format. Regardless, if there is a missing digit in the 5-4-2 format, a zero must be added to the beginning of one of the three number sections, whichever section is deficient, in order to bring the number into 5-4-2 claim-submitting compliance. For example:

What are the differences between medical and pharmacy billing?

Below are the primary differences between medical and pharmacy billing.

Medical claims

• Usually billed in mg.*
• One J-code represents multiple NDCs.

Pharmacy claims

• Usually billed in ml.*
• The NDC is highly specific and should match the vial administered to the member.
• The NDC must be in the appropriate 5-4-2 format to match our validation file. Refer to the 5-4-2 format explanation above.

*Therefore, the quantity billed and unit of measure qualifier will rarely match between the HCPC (J-code) and NDC. See the commonly billed J-codes (PDF) to NDC billing cross-reference guide for more information.

I need help converting J-code units to NDC. Do you have a resource?

We have created a commonly billed J-codes user guide (PDF)Opens a new window.

Once you have identified the number of J-code units you will bill, simply take these units, divide by the conversion factor —denoted as "CF" — and this will provide the appropriate number of NDC units to bill. The proper NDC unit qualifier has also been listed to ensure that this is properly selected. Let's look at a few examples below:

Example #1 pegfilgrastim

• J2505 = 6mg.
• Each syringe administered equals one J-code unit.
• Available as a 6mg/0.6mL syringe.
• The conversion factor is 1.66 so the NDC quantity is 1/1.66 = 0.6.
• The unit qualifier is "mL."

For illustrative purposes only.

Example #2 trastuzumab

• J9355 = 10mg.
• Each vial contains 440mg or 44 J-code units.
• The conversion factor is 44 so the NDC quantity is 44/44 = 1.
• Even though it is an MDV, it is listed as "Each" which is reported with the unit qualifier "UN" for unit.

For illustrative purposes only.