Dear Participating Provider,
Effective June 1, 2019, Community First health Plans (CFHP) implemented a new core claim processing platform called QNXT. Electronic or Paper claims submitted on or after June 1, 2019 to CFHP should be submitted using the Medicaid issued ID for all STAR Kids and Children’s Health Insurance Plan (CHIP). To allow for Providers to make this adjustment to their submissions, CFHP will continue to accept the CFHP issued subscriber ID for Medicaid and CHIP claims through August 15, 2019. Please do not resubmit claims that have been previously submitted, CFHP has processed those claims through the new QNXT system if they were “Accepted”. Providers should resubmit corrected claims to CFHP that have been “Rejected” per their clearing house reports.
Providers may continue to submit with the “A” or subscriber unique ID number for CFHP Commercial HMO and University Family Care Plan member claims.
Below, Providers will find helpful instructions related to billing clean claims for services to CFHP. Previously, CFHP did not “Accept” or “Reject” claims, CFHP processed all claims received. However, with the conversion to the new QNXT platform, CFHP will not edit claims for certain “clean” claim data requirements before adjudicating a claim. Claims received with missing or non-compliant elements will be “Rejected” back to the provider through the 277CA claim receipt report provided by the CFHP contracted clearing houses. The reports will have message information to direct the submitted as to the missing or non-compliant element so that the claim can be corrected and resubmitted. Claims that pass the initial review will be accepted into the QNXT system and adjudicated to a “Paid” or “Denied” status.
Additional requirements will also apply:
If these data elements are missing or invalid, claims will be rejected via a 277 CA clearing house claim report.
Provider(s) taxonomy (rendering and billing) will be considered invalid if the submitted taxonomy is not one of the NPI and taxonomy combinations with which the provider has reported and enrolled with Texas Medicaid & Healthcare partnership (TMHP). It is critical that the taxonomy code selected and used in claim submission is included on all electronic and paper transactions in the correct combination based on the services being billed.
Note that “Rejected” claims do not count as a clean claim; please ensure that claims are submitted within 95 days from the date of service. Per the HHSC contract requirements, a clean claim must have all the necessary data from the claim processor to adjudicate and accurately report the claim. Clean Claims must meet all the requirements for accurate and complete data as defined in the appropriate claim type encounter guides.
For any questions regarding this information, please contact Manny Monreal, Network Management Provider Relations Representative at 210-358-6294 or via email at firstname.lastname@example.org.
Director of Network Management
Community First Health Plans