Provider Claims Tools
SilverSummit Healthplan strives to provide the best tools and support you need to deliver the best quality of care. Please view our listings on the left, or below, that covers claim resources, guidelines, and helpful links.
Claims and Payment Frequently Asked Questions
Take a look at our Claims and Payment FAQ document for answers to over 30 of the most commonly asked claims-related questions.
- Claims and Payment Frequently Asked Questions (PDF)
- Claims Processing Reference Guide -coming soon
Claims Reconsiderations and Claim Payment Appeals
A Request for Reconsideration (Level I) is a communication from the provider about a disagreement with the manner in which a claim was processed.
A Claim Appeal (Level II) is defined as a request from a health care provider to change a decision made by SilverSummit Healthplan related to claim payment for services already provided. A provider claim payment appeal is not a member appeal (or a provider appeal on behalf of a member) of a denial or limited authorization as communicated to a member in a notice of action.
The Request for Reconsideration or Claim Appeal must be submitted within 60 calendar days from the date of the Medicaid Remittance.
If the original claim submitted requires a correction, please submit the corrected claim following the “Corrected Claim” process in the Provider Manual. Please do not include this form with a corrected claim.
For fastest service, submit your Claims Reconsideration via the Provider Portal.
Or you can also complete and mail in the following forms:
o Reconsideration: Claim Reconsideration form (PDF)
o Appeals: Claim Appeal form (PDF)
Check to see what Provider form will be required to submit, what address to mail forms to and timely filing information on our Quick Reference Guide for Claims, Reconsiderations, and Appeals(PDF).
SilverSummit’s Payment Policies
All SilverSummit HealthPlan Payment Policies, which are used to help identify whether health care services are correctly coded for reimbursement, can be found on our Clinical & Payment Policies Page.
Please see below for latest policy updates and effective dates
Policy Number | Policy Name | Policy Description | Line(s) of Business | Effective Date |
|---|---|---|---|---|
| CP.MP.100 | Allergy Testing and Therapy | Change codes 86160, 86161 and 86162 from not payable to NOT payable only when billed with the following diagnosis codes: B44.81, H10.01* through H10.45, J30.1 through J30.9,J30.0, J31.0, J45.2* through J45.998 , L20.84 , L20.89, L20.9,L23.0 through L23.9*, L25.1 through L25.9, L27.0 through L27.9, L50.0, L50.1, L50.6, L50.8, L50.9, L56.1, L56.2, L56.3, R06.2,T36.0X5A through T50.995S , T63.001* - T63.94*, T78.00X* through T78.1XXS, T78.49XA through T78.49XS , T80.52XA through T80.52XS, T88.6XXA through T88.6XXS, Z88.0 through Z88.9, Z91.010 through Z91.018, Add the following diagnosis codes as payable with 86003,86005, 86008, 95004, 95017, 95018, 95024, 95027 and 95028. L20.0, L20.81-L20.83, L24.9, L30.2. Add CPT 86001 as NOT payable. | Medicaid Marketplace | 05/15/2023 |
| CP.MP.97 | Testing for Select Genitourinary Conditions | Added 0330U and 0352U as not med nec for members over age 13 (new code for July '22 with no utilization/cost data). Changed matching requirements for ICD-10 B37.3 to apply to B37.31 and B37.32 which together now replace B37.3. There will be no savings change from this edit. Changed CPT 87481 from not medically necessary in any circumstance to not med nec when paired with the following dx codes, and only applied to members 13 years and over. Required the same dx code matching for new code 0353U (with no utilization/cost data): B37.31, B37.32, L29.2, L29.3, N39.0,N72, N76.0, N76.1, N76.2, N76.3, N76.81, N76.89, N77.1, N89.8, N89.9, N90.89, N90.9, N91.0 –N91.5, N92.0, N93.0, N93.8, N93.9, N94.3, N94.4 – N94.6, N94.89, N94.9, O09.00-O09.03, O09.10-O09.13, O09.A0- O09.A3, O09.211-O09. 219,O09. 291-O09. 299,O09.30- O09.33,O09. 40-O09.43, O09.511-O09.519, O09.521- O09. 529, O09.611-O09.619, O09.621-O09.629, O09.70-O09.73, O09.811- O09.819, O09.821-O09.829, O09.891-O09.899, O09.90- O09.93, O23.511– O23.93,Z00.00,Z00.8,Z01.419,Z11.3,Z11.51,Z22.330,Z23,Z30.011 – Z30.019,Z30.02, Z30.09,Z30.40 – Z30.9,Z32.00, Z33.1, Z34.00 – Z34.03, Z34.80 – Z34.83, Z34.90 – Z34.93, Z36.0-Z36.5, Z36.81- Z36.9, Z38.00 – Z38.01, Z38.30 – Z38.31, Z38.61 – Z38.69, Z39.0 – Z39.2, Z3A.00 – Z3A.49, Z72.51 – Z72.53, Z86.19, Z97.5 | Medicaid Marketplace Medicare | 05/15/2023 |
Claims Resources
SilverSummit Healthplan strives to supply our providers with update to date claim billing information and reference guides. For our current selection of guides and tip sheets, please see our claim reference guides below:
- Claims Processing – coming soon
- Claim Status (PDF)
- Corrected Claims Reference Guide (PDF) (includes web portal submissions)
- CMS 1500 Claim Form Instructions (PDF)
- CPT Category II Codes (PDF)
- Denial Codes crosswalk – coming soon
- EXwD code edits (PDF)
- ICD-10 Correct Coding Edits – coming soon
- Place of Service Codes (PDF)
- Reconsideration Quick Reference Guide (PDF)
- Reject reason code and descriptions – coming soon
- UB04 Billing Guide– coming soon