Submitting a Claim

Electronic claim submission is the preferred method for submitting your claims to Affinity Medical Group.

Affinity Medical Group remains committed to maintaining the highest standards of quality and efficiency among its practices. Electronic claims submission represents a significant opportunity for practices and the Medical Group to improve productivity and efficiency. Benefits of electronic claims submission include:

• Reducing paperwork and costs associated with the printing and mailing of paper claims.
• Reducing the likelihood of transcription errors and incomplete data as errors are instantaneously returned to the submitter through the electronic channel.
• Improving the turnaround time on claims payments.

In the interest of greater efficiency, Affinity Medical Group strongly encourages all of its physicians to participate in electronic claims submission.

Affinity receives claims electronically through three clearinghouses:

Clearinghouse (Submitter Number)

For help establishing electronic claim submission, contact Affinity Customer Service at (800) 615-0261.

Other Billing Requirements

There are special requirements for the following types of bills.

Anesthesia Providers

• Box 24G (Quantity Billed) should reflect the number of minutes
• Injectable Medication and/or Other Drugs Reimbursed at Average Wholesale Price
• Paper format ONLY
• NDC must be provided.

Coordination of Benefits (COB)

Affinity is secondary:

• No copayment should be collected from the member.
• A claim should be submitted to the primary insurance carrier first.

Upon receipt of payment from the primary carrier, a claim should be submitted to Affinity along with a copy of the EOB from the primary carrier. Affinity will process the claim and pay the lesser of the remaining member responsibility or the Affinity contracted allowable for the service. If service falls under the cap, charges will be capitated accordingly and the member cannot be billed.

Affinity is both the primary and secondary carrier:

• No copayment should be collected from the member.
• Two claims should be submitted to Affinity for processing: one claim should include the primary coverage policy information and the second claim should contain the secondary policy information. There is no need to attach a primary EOB from Affinity.
• The primary coverage claim will be processed according to the contracted rates; Affinity’s explanation of benefits will reflect any applicable copayment amounts. Capitated services will be processed as such.
• Any applicable copayment amount outstanding will be covered by Affinity through the secondary carrier policy. Affinity will process the secondary claim and pay the lesser of the remaining member responsibility or the Affinity contracted allowable for the service. Capitated services will be processed as such. If service fall under cap, charges will be capitated accordingly and the member cannot be billed.

For claims not submitted electronically

The following requirements must be met to minimize the potential for rejection of claims, delays in processing, and/or identification of problems.

• Paper claims must be submitted on a CMS-1500 or UB-04 form and mailed directly to the Affinity Claims department at:

Affinity Medical Group
PO BOX 425
Newark, CA 94560-0425

• Superbills and handwritten forms will NOT be accepted. CMS-1500 forms should be typed or computer-generated with clear and legible print.
• The patient’s name, address, date of birth and insurance information must be completed fully on each claim form submitted. Please print the patient’s name exactly as it appears on the ID card. Nicknames and initials cause delays in paying your claims as they cannot be matched to health plan eligibility records.
• Claims must be billed using current CPT codes with a Medicare published reimbursement and Level II HCPCS codes for supplies and injectables.
• Boxes #25 (Federal Tax ID #), #31 (Signature of Physician) and #33 (Physician Name and Address) must be completed on each CMS-1500 claim form submitted.
• Box #23 on the CMS-1500 form should contain the Provider NPI.
• Box #63 on each CMS-1500 and UB-04 should contain the authorization number. The Name of your Practice/Medical Group must be clearly marked on each CMS form submitted.

Submit any additional pertinent documentation related to the claim.

Timely Submission is required
Claims should be submitted within the timeframe specified in your contract. Most contracts require that claims be submitted within ninety (90) days from the date of service. Your medical group accepts no obligation to pay claims received after the timeframe in your contract.

Coordination of Benefits
An exception to the timeframe includes Coordination of Benefits (COB) claims where collection from a primary source is required prior to billing your medical group. In these cases, submission is required ninety (90) days from the date payment is received from the other carrier.

Health Plan Payments (claims that are the responsibility of the Health Plan)
Claims requiring health plan payment should be forwarded directly to the appropriate health plan. Claims that are sent to Affinity inadvertently will be redirected to the health plan or to the party responsible for payment.

Balance Billing
The Knox-Keene Act, California Health and Safety Code Section 1340 et. seq. specifically prohibits the practice commonly known as “Balance Billing” where a Contracted Provider attempts to collect the outstanding balance that is not paid by the Plan for services rendered to the member.

Provider Resources

• Join Affinity Medical Group
• Affinity Provider Portal Information
• Operating Hours & Holidays
• Referrals & Authorizations
  • Health Plan Contact Information
  • Transition of Care Form
  • Provider Demographic Data Form
  • Policies & Procedures
  • Utilization Management Statement on Incentives & Timely Access Standards
  • Utilization Management Statement on Availability of Criteria
  • Patient Access to Care