Frequently Asked Questions - Providers & CA

To change your address, it is necessary to complete the Provider Information Form, Location Information Form, and a W-9 form. The forms are also available in the credentialing documents

You may fax the completed forms to 770-455-6188 or mail to:

ActivHealthCare, Inc.
P. O. Box 1368
Lilburn, GA 30048

To change your tax ID, it is necessary to complete a W-9 form. The form is also available in the credentialing documents.

You may fax the completed form to 770-455-6188 or mail to:

ActivHealthCare, Inc.
P. O. Box 1368
Lilburn, GA 30048

Sometimes, depending on what was not paid and the reason.

For example, patients are responsible to pay you for co-pays, deductibles and coinsurance portions that are not paid by the insurance carrier. The patient may also be billed for items that are specifically not covered by the insurance plan, i.e. vitamins, cervical pillows, massages, etc. However, you must let the patient know in advance and in writing that certain items may not be covered and will be the patient's financial responsibility.

The patient is not responsible for the portion of the claim that is denied due to PPO or network discounts. As a participating provider, you are agreeing to a fee schedule that is set by the PPO network and is approved by ActivHealthCare. If your charge for a particular CPT code is over the fee schedule, the insurance carrier or claims administrator may deny a portion of your claim. You cannot bill the patient for the portion of the claim denied for this reason.

However, benefit plans often have limits on chiropractic care. Some plans limit the maximum benefit payable per visit, some limit the number of visits per benefit year and some limit both. You can bill the patient for claims that exceed the plan limits, up to the fee schedule amount for the services rendered. For example, if the services add up to $75 and the fee schedule for the services adds up to $58, the plan limit might be only $50 per visit. The patient is still responsible for the additional $8, if you choose to hold them responsible for it. Again, you should let the patient know in advance and in writing that they may be responsible for certain items and for services that exceed their plan limits. Our bulk pay remittance will distinguish between PPO or Network discounts and plan limits.

Some insurance plans require pre-certification of treatments, especially HMOs. You have an obligation to follow the rules of the patient's insurance plan. If you fail to obtain pre-certification and it is required, your claim might be denied. The patient and the plan will expect you to write off this type of denial. With that in mind, be sure to get clear answers to questions when verifying benefits.

And finally, some patients will change carriers and not notify you. They may provide you with the incorrect information. While you have an obligation to file claims in a timely manner, you cannot do so without the patient providing correct information. If the claim is denied because the patient did not provide accurate information, but you acted in good faith, you should balance bill the patient.

NPIs would be issued by the National Provider System (NPS) based on information entered into the NPS by one or more organizations known as

The NPI must be used in connection with the electronic transactions identified in HIPAA. In addition, the NPI may be used in several other ways:

(1) by health care providers to identify themselves in health care transactions identified in HIPAA or on related correspondence;

(2) by health care providers to identify other health care providers in health care transactions or on related correspondence;

(3) by health care providers on prescriptions (however, the NPI could not replace requirements for the Drug Enforcement Administration number or State license number);

(4) by health plans in their internal provider files to process transactions and communicate with health care providers;

(5) by health plans to coordinate benefits with other health plans;

(6) by health care clearinghouses in their internal files to create and process standard transactions and to communicate with health care providers and health plans;

(7) by electronic patient record systems to identify treating health care providers in patient medical records;

(8) by the Department of Health and Human Services to cross reference health care providers in fraud and abuse files and other program integrity files;

(9) for any other lawful activity requiring individual identification of health care providers, including activities related to the Debt Collection Improvement Act of 1996 and the Balanced Budget Act of 1997.

After the standard is announced in the Final Rule in the Federal Register, the NPS will begin assigning NPIs to health care providers based on information they supply on NPI applications. Because there are so many providers, HHS recommended in the Notice of Proposed Rule Making that assignment of the NPI be done in phases. We expect that providers that conduct any of the transactions specified in HIPAA would be among the first to be enumerated.

Two years after the adoption of this proposed standard, the NPI must be used by health plans, health care clearinghouses, and those health care providers that conduct electronic transactions specified by HIPAA. Small health plans have 3 years to comply.

NPIs would be given to health care providers that need them to submit claims or conduct other transactions specified by HIPAA. A health care provider is an individual, group, or organization that provides medical or other health services or supplies. This includes physicians and other practitioners, physician/practitioner groups, institutions such as hospitals, laboratories, and nursing homes, organizations such as health maintenance organizations, and suppliers such as pharmacies and medical supply companies. This does not include health industry workers, such as admissions and billing personnel, housekeeping staff, and orderlies, who support the provision of health care but do not provide health care services.

Today, health plans assign identification numbers to health care providers -- individuals, groups, or organizations that provide medical or other health services or supplies. The result is that providers who do business with multiple health plans have multiple identification numbers.

The NPI is a unique identification number for health care providers that will be used by all health plans. Health care providers and all health plans and health care clearinghouses will use the NPIs in the administrative and financial transactions specified by HIPAA. The NPI was proposed as an 8-position alphanumeric identifier. However, many commenters preferred a 10-position numeric identifier with a check digit in the last position to help detect keying errors.

The NPI contains no embedded intelligence; that is, it contains no information about the health care provider such as the type of health care provider or state where the health care provider is located.

The two most viable options are described below. The Notice of Proposed Rule Making welcomes feedback on these options, as well as on alternate solutions. Because the data needed to enumerate Medicare providers is already available in HCFA files, that information will be loaded into the National Provider System and NPIs will be assigned automatically to Medicare providers under either option described below. Medicare providers, therefore, would not have to apply for an NPI.

Option 1: A Federally-directed registry would be the enumerator of all health care providers.

After the initial load of Medicare provider data and assignment of NPIs to Medicare providers, all the remaining health care providers would apply directly to the registry for an NPI. The registry could be operated by an agent or contractor. The registry would enter the provider's data into the National Provider System; the National Provider System would assign an NPI, and the registry would notify the provider of the NPI.

Option 2: A combination of Federal programs (health plans), Medicaid State agencies, and a registry would be enumerators.

Federal programs and Medicaid State agencies would enumerate their own health care providers by entering provider data into the National Provider System; the National Provider System would assign NPIs to the providers. Each health care provider participating in more than one Federal or Medicaid health plan could choose the one by which it wishes to be enumerated. All other health care providers would apply directly to a Federally-directed registry for an NPI.

By submitting claims through AHC you will receive in-network benefits. In most cases, this means lower deductibles and higher claims reimbursements. AHC is not a billing service, but we provide a centralized billing service for your paper claims. You can contact us for claims status on numerous patients at one time as opposed to making several phone calls to multiple companies. We will communicate to you the information we receive from the carriers. We will provide a single, easy to read bulk pay remittance that summarizes the information on the various explanations of benefits we receive. If you have any questions, we are here to help.

AHC has contracted with numerous networks throughout the Southeast. (Over 30 contracts are currently in place.) These networks are often referred to as managed care organizations (MCOs), preferred provider organizations (PPOs) or health maintenance organizations (HMOs). For a complete list, please view our current contracted networks.

No, they probably will not. Remember, we contract with the PPO, HMO or MCO network. We do not contract directly with the claims payor. The PPO, HMO or MCO has the contract with the claims payor. For example, the claims payor normally does not know that Southcare uses AHC chiropractors. There are several hundred companies paying Southcare claims throughout the country. By contracting with AHC, your name is placed in the directories of all the Southcare PPO plan participants.

By joining AHC you will have access to the patients that use our affiliated networks. Currently we have over 30 affiliated networks. You will only have to credential and pay one network, AHC, not 30. We will handle the credentialing audits for you.

Yes, there is a small administrative or access fee. We are offering you access to network plan participants through your affiliation with us. These fees are usually offset by higher claims reimbursements because of the increased in-network benefits.

You would call the number on the insurance card to verify coverage and obtain a description of benefits. In some cases the insurance carrier will ask for your tax identification number to determine if you are a participating provider. If that happens, you should provide them with AHC's tax identification number.

Be sure to ask about co-pays, deductible, coinsurance percentages, effective dates, chiropractic benefits and the other information listed on your insurance verification form. If the claim is for an accident, be sure to let the carrier know at the point of insurance verification. Your goal in the verification process is to obtain an accurate estimate of what will be allowed and paid by the carrier and what financial responsibility the patient will have to you.

Please refer to the credentialing information. If you have questions or concerns please contact us

The employer or insurance carrier will identify the PPO which the patients should use by placing either the name or logo of the MCO or PPO on the insurance identification card. If it is not on the identification card, you should ask for the name of the PPO network when you verify insurance coverage.

If the patient's coverage uses an affiliated network, but the claims payor or insurance carrier does not recognize you as a participating provider contact the AHC customer service department.

These companies build a large group of preferred providers and sell the rights to access the providers to insurance carriers, third party administrators, and employee benefit plan administrators. The plan participants (or patients) of the employee benefit plans that are using these contracted networks refer to the PPO directory or provider list when they need to select a participating provider. If you are a member of AHC, your name is listed in the directory. In other words, you get more patients.

No, not unless you have a direct contract with the PPO, HMO or MCO. You are listed as a PPO, HMO or MCO participating provider through your affiliation with AHC. As such, you are recognized by the AHC tax identification number and billing address.

You should only submit the claims for patients affiliated with the AHC contracted networks. Most of our contracts require you to submit the claims through AHC. A few of the contracts provide for direct billing from you to the payor. Those contracts are identified on our list of current contracted networks.