You will see a reduction in pended claims and denials by following these helpful tips when submitting your claims:
- Verify member eligibility at time of service.
- Follow Medi-Cal billing guidelines.
- Use the appropriate claim form. Please do not use a photocopy. The original redlined claim form is required.
- Provide valid procedure and diagnosis codes (do not include any additional zeros or numbers).
- Include appropriate revenue codes (must be included on UB04).
- Provide the Tax ID Number (TIN).
- Provide the NPI for the billing provider, rendering provider and attending physician, as appropriate.
- Denote whether the member has other health insurance (OHI).
- Submit claims electronically through a Plan-approved electronic billing systems software vendor or clearinghouse. Completion of electronic claims submission requirements can speed claim processing and prevent delays. If you are not currently submitting claims electronically and would like to learn more about EDI and how to get connected, please click here or contact EDI Customer Support by phone at 1.800.952.0495 or by email at EDICommercialSupportTeam@Conduent.com.
- Submit paper claims by mail (GCHP cannot process claims submitted via facsimile) to:
Gold Coast Health Plan Attn: Claims
P.O. Box 9152 Oxnard, CA 93031
For more information or for questions, contact Customer Service at 1.888.301.1228.
Providers and clearinghouses are required to enroll as a Trading Partner to submit claims electronically. Please direct questions to EDI Customer Support at 1.800.952.0495 or by email to email@example.com. View more information about EDI.
Helpful Tips 999 and 997 Responses
- A response file will be produced and posted to your trading partner mailbox for each file you submit to Xerox EDI Direct. It is imperative that you retrieve your response files to determine whether your files were accepted, errored or rejected. If your response file contains any value other than an "A" in the IK5, AK5 or AK9 and you are unsure of the error or rejection, please contact our EDI Commercial Support Team at the number or email below.
- The most common rejections identified are the subscriber ID and the secondary ID (Legacy IDs).
- The subscriber ID in loop 2010BA NM109 should be a 9-byte ID (8 numerics + 1 letter).
- Secondary IDs or Legacy IDs should not be present in the provider loops, with the exception of the tax ID in the 2010AA Billing Loop.
- GCHP Companion Document
- EDI Direct 5010 Communications Document
- WinASAP5010 quick reference guide
- EDI Direct 835 Transaction Form
EDI Commercial Support Team
Government Healthcare Solutions
Gold Coast Health Plan (GCHP) supports electronic funds transfer (EFT). Providers who enroll in EFT will have their Medi-Cal payments directly deposited in their checking or savings account. The EFT option is currently available to in-network providers in Ventura County.
Q: What happens if claims are not submitted in a timely manner? (Beyond the 180 days suggested filing date.) Will claims be paid at a reduced rate like Medi-Cal or denied?
A: Yes, Gold Coast Health Plan (GCHP) follows the Medi-Cal payment reduction for claims received more than 180 days after the date of service or date of discharge. Claims submitted beyond 365 days from the date of service or date of discharge will be denied.
Q: I received a denial for a specific procedure code (e.g., 82106 ZS) stating that it is not the financial responsibility of GCHP and was directed to bill Medi-Cal FFS. Where should I send the claim?
A: Please contact Medi-Cal directly at 1.800.541.5555 or visit the Medi-Cal website for more information. There are some specific procedure codes that are not covered by GCHP but are still covered by Medi-Cal and paid by the state’s Fiscal Intermediary. The EOP will provide the correct payer information.
Q: Who can I contact if GCHP customer service is unable to assist with claim underpayment or overpayment discrepancies?
A: Please send an e-mail to ProviderRelations@goldchp.org with your provider ID (if applicable), NPI number and TIN number. Please include a brief summary of your issue and a Provider Relations representative will respond and escalate the matter to other departments (Claims, Finance, etc.) if necessary.
Q: How are claims for newborns to be billed?
A: Services rendered to an infant may be billed with the mother’s ID number for the month of birth and the following month. After this time, the infant must have his / her own subscriber ID number.
Q: Who can I contact if customer service is unable to assist with specific benefit coverage or claims questions and I have not received a response within 24 to 48 hours?
A: Please submit written questions via email directly to ProviderRelations@goldchp.org.
FOR A MORE COMPLETE LIST OF FAQs ON CLAIMS RELATED ISSUES, PLEASE REFER TO THE GCHP PROVIDER MANUAL, SECTION 10.