The clearinghouse would like to remind providers that claims with dates of service prior to April 1, 2013 must continue to be submitted to WPS. Claims with dates of service on or after April 1, 2013 must be submitted to PGBA.
Claims with dates of service prior to April 1, 2013, must continue to use CPID 7452 for Professional and CPID 3552 for Institutional claims (Payer ID WESTR). These will be sent to WPS.
Claims with dates of service on or after April 1, 2013, must use new CPID 6286 for Professional and CPID 5648 for Institutional claims (Payer ID 99726). These will be sent to PGBA.
Please use the TriWest Transition Claims Processing Matrix
to determine how to submit claims based on dates of service and admit and discharge dates to ensure they are routed to the correct contractor. Both WPS and PGBA have processes in place to forward claims to the appropriate processor based on dates of service should they mistakenly receive claims for each other. Please note, if a claim spans dates it will be manually split and the appropriate service lines will be dropped to paper and forwarded to the correct processor. To avoid delays in claim processing and payments, please review the matrix and submit claims accordingly to the appropriate CPIDs.
Payer Edit AW1 Rendering Physician is required:
If the Billing/Pay to Provider is a group, then the Rendering Provider is required. Providers should ensure they are sending the Group Name and Group NPI as the Billing Provider and sending the Rendering Provider Name and Rendering NPI as the Rendering Provider. Claims may reject with payer edit AW1 Rendering Physician is required if the Rendering Provider's Name and NPI are not present when billing as a group.
If the Billing/Pay to Provider is a solo practitioner and payer edit AW1 Rendering Physician is Required is encountered, please contact Provider Data Management at United Healthcare Military Customer Service 1-877-988-9378 to confirm setup.
Action Required: Providers should be aware of these updates and take necessary actions to avoid claim processing delays.
If you have any questions, please contact Client Services at 1-888-348-8457, option 2.