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Although PHCS does not pay claims, we do negotiate reimbursement on a fee-for-service
basis. A sample fee schedule for the most commonly billed procedure codes was included
with your PHCS application. For your information, the reimbursement process is as follows:
- Submit all of your normal charges to the claims address on your patient's PHCS ID card.
- The health plan will then either pay the billed charges or the PHCS negotiated rate, whichever is lower.
- For procedure codes that do not have a specified rate, payment is based on the billed charges or the customary charge, whichever is lower.
If you have a patient who requires multiple surgical procedures, it is important to verify
the benefit coverage with the patient's health plan for each individual procedure
involved. This will help to avoid a reduction in the patient's benefits that may be caused
by multiple procedures being performed under one anesthesia.
Submitting Claims
There are two ways to submit a claim.
- By mail to the address found on the patient's ID card using a CMS-1500 or UB92 claim form
- Electronically through transaction networks and clearinghouses in a process known as
Electronic Data Interchange (EDI). This method promotes faster, more accurate processing
than with paper claims that are submitted by mail and is a requirement for federal
benefit plans. For additional EDI information, please refer to the patient’s ID card
to obtain the payor identification number of the clearinghouse used for claims
submission.
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