Provider Billing Resources

For in-network providers, access CountyCare’s Provider Portal and Provider Portal User Guide in order to:

Healthcare and Family Services (HFS) Billing Resources

HFS and related agencies frequently update guidelines, fee schedules, reimbursement guidelines, etc. Once CountyCare is notified of any updates or changes (retroactively and prospectively), we have 30 days to implement said system updates (retroactive and proactive).

Claims Processing

CountyCare has partnered with Evolent Health to process claims. Claims eligible for payment must meet the following requirements:

  • The member is effective with CountyCare Health Plan on the date of service
  • The service provided is a covered benefit under the member’s contract on the date of service
  • Referral and prior authorization processes were followed, if applicable
  • Claim was received within 180 calendars days from the date of service, or date of discharge, whichever is later. This limit may be extended where eligibility has been retroactively received by CountyCare up to a maximum of 180 days.
  • Corrected claims must be submitted within 60 days of the EOP, or 180 days from the date of service, whichever is later.

Providers have the right to request a review of any claim decision made by CountyCare within 60 calendar days from the date of the Explanation of Payment (EOP) or Remittance Notice. Provider claim reviews may be submitted electronically through the Provider Portal  or by mail using the Claim Review form  for any of the following denial reasons: timely filing, review of contract rate/payment, duplicate claim, authorization, or other unforeseen reason.

For more detailed information on claims submission and adjudication, please click here to view the Provider Manual.

Claims Projects

Please review the reports below for details around current or recently completed Claims and Configuration projects from CountyCare. The report outlines project description, impacted providers, expected resolution, current status, and expected completion date, when known. If you have any questions about the projects on this report, please contact your Provider Relations Representative.

Electronic Transactions

Network providers are encouraged to participate in CountyCare’s electronic claims/encounter filing program. You or your billing agent will need to utilize a third-party claims clearinghouse vendor to submit electronic claims. CountyCare can receive ANSI X12N 837, or most current version, professional, institution or encounter transactions. In addition, it can generate an ANSI X12N 835, or most current version electronic remittance advice known as an Explanation of Payment (EOP).

Providers that bill electronically have the same timely filing requirements as providers filing paper claims. In addition, providers that bill electronically must monitor their error reports and evidence of payments to ensure all submitted claims and encounters appear on the reports. Providers are responsible for correcting any errors and resubmitting the affiliated claims and encounters.

CountyCare’s Payor ID is: 06541.

CountyCare’s Clearinghouse vendor is Availity.