Covered Participants are never required to file a claim when Covered Services are provided by Preferred (In-Network) Providers. When they receive care from a Non-Preferred (Out-of-Network) Qualified Provider, they will need to file a claim or have their provider file a claim for the covered participant to receive reimbursement. For out-of-network claims please contact the Manager of Network and Provider Relations at (215) 746-7906 or via email.
In some cases, at the discretion of the Carrier, arrangements may be made to have payments made directly to the provider such as in the case of a facility or other hospital setting.
Preferred (In-Network) Providers of PENN Behavioral Health must notify University of Pennsylvania and University of Pennsylvania Health System Covered Participants of their In-Network status prior to billing so Covered Persons will know not to submit claims.
Preferred (In-Network) Providers must also notify PENN Behavioral Health for a pre-claims benefit determination to assure their eligibility and benefit coverage. Failure to notify PENN Behavioral Health prior to treatment may result in forfeiture of payment or delay in claim processing.
Preferred (In-Network) Providers are expected to submit "clean claims" for prompt processing and payment. A "clean claim" must contain no defect or impropriety, including a lack of any required substantiating documentation, HIPAA compliant coding or other particular circumstance requiring special treatment that prevents timely payment from being made.
If at any time PENN Behavioral Health requires additional information from any party external to PENN Behavioral Health, the claim is no longer considered a "clean claim" and may be referred as an "unclean" or contested claim.
It is the Provider's responsibility to:
It is PENN Behavioral Health's responsibility to:
Claims should be filed with the Claims Department within the 60 days of the date charges for the services were incurred. Benefits are based on the Plan's provisions at the time the charges were incurred.
Claims filed later than that date may be declined or reduced unless:
(a) it's not reasonably possible to submit the claim in that time; and (b) the claim is submitted by the end of the 90 day deadline from the time when the claim was incurred.
If it is not possible to file the claim within the 60-day period, the provider must submit in writing the reason for the delinquent claim, but in no event will the Plan be required to accept the claim submitted more than 90 days after the end of the Benefit Period in which the Covered Services are rendered.
Providers who have questions regarding claims can call PENN Behavioral Health Member Services (Access Services Department) at (1-888-321-4433) and the full process for filing a claim will be described.
The provider must include the above pertinent information and return it with any itemized bills to:
PENN Behavioral Health
3535 Market Street, 4th Floor
Philadelphia, PA 19104
Please submit claims no later than 60 days after the completion of the Covered Services. The claim should include the date and information required by the Carrier to determine benefits.
The Claims Administrator will determine if enough information has been submitted to enable proper consideration of the claim. If not, more information may be requested from the claimant. The Plan reserves the right to have a Plan Participant seek a second medical opinion.