Provider Manual

CLAIMS ADJUSTMENTS

Please note that claims adjustments are not currently a capability in the Availity portal.

All claim adjustments must be submitted by mail, facsimile (855-439-2443), web inquiry (ProviderConnect), or phone to the Carelon Engagement Center within 90 days of the date of the provider summary voucher.  Requests for adjustments to outpatient claims may also be submitted via ProviderConnect by utilizing ProviderConnect Change/Reprocess of Professional Claims for all corrections to CMS-1500 or 837 Professional Claims. To access ProviderConnect, visit https://pa.carelon.com/providers. To obtain a User ID, click on register, complete the required form, and click on “submit.”

If there is an error on your claim, please contact a Member and Provider Service Representative at 877-615-8503. When calling the engagement center to request an adjustment, status a claim, or verify authorization, please have the following information available:

• Provider Tax Identification Number and/or NPI
• Member’s ID number
• Member’s Date of Birth
• Claim Number (if known)

When sending in a corrected claim via mail or fax, please include the following information:

• Reason for correction
• Copy of the Provider Summary Voucher
• Primary Insurance Explanation of Benefits (EOB)

Please mail all correspondence regarding claims questions to:

Carelon
Pennsylvania Claims
P.O. Box 1853
Hicksville, NY 11802-1853

This address is to be used for all paper claims submissions (new or corrected claims).