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Claims Documents

This is the place for providers to find Claims-related forms and other documents.

You can also find them on the Provider Documents page, but we thought: Why not make it as easy for you as possible? 

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Claim Form - LTC Professional

Providers use this form to submit claims for long term care professional services rendered to iCare Family Care Partnership members. Updated 2019.

Plans
  • iCare Family Care Partnership

Claim Form - LTC Residential

Providers use this form to submit claims for long term care residential services rendered to iCare Family Care Partnership members. Updated 2019

Plans
  • iCare Family Care Partnership

Clean Claim Requirements (CMS 1500)

The Centers for Medicare and Medicaid Services (CMS) developed claim forms that record the information needed to process and generate provider reimbursement. This document summarizes the required elements that must be complete, legible and accurate to be handled as a clean claim.

Plans
  • ALL

Clean Claim Requirements (UB-04)

The UB-04 form captures essential data elements as defined by the National Uniform Bill Committee for providers of services in institutional/inpatient/facility settings. This document summarizes the required elements that must be complete, legible and accurate to be a clean claim.

Plans
  • ALL

Electronic Remittance Advice (ERA) Request Form

Providers use this form to request Electronic Remittance Advice (ERA) enrollment.

iCare Provider Portal User Guide

iCare’s Provider Portal allows you to bill your LTC Professional claims, view service authorizations and view claim information for the iCare members you serve using your personal computer, cell phone or tablet

iCare Remit Reason Codes

Remittance Reason Codes provide additional explanation for a claim

Plans
  • ALL

ICD10 FAQs

The new classification system provides significant improvements through greater detailed information and the ability to expand to capture additional advancements in clinical medicine.

ICD10 Links

Links to resources to help understand ICD10 claims updates

Portal Access Request Form

iCare's Provider Portal allows you to view service authorizations and view claim information for the iCare's members you serve. You can request a PIN number by emailing the completed Portal Access Request Form to netdev@iCareHealthPlan.org

Reconsideration-Formal Appeal Form

Providers use this form to appeal or dispute a claim denial or claim payment amount.

Remittance Advice Guide

A provider or biller uses this guide to post payments and review claim adjustments. It contains specific claim decision information, includes adjustment reasons and codes and allows for review of denied, paid, overpaid or underpaid claims.

Review/Reopening Form

A provider uses this form to dispute a claim denial or claim amount.

Status Check Request Form

The Status Check Request Form is a form for providers to fill out to request information about a claim.

Taxonomy Code Requirements

This communication is in response to questions brought to our attention regarding claim submission requirements for iCare Medicaid claims.

Leaving iCareHealthPlan.org

By clicking this link, you may be leaving the iCareHealthPlan.org website. Independent Care Health Plan (iCare) only provides these links and pointers for your information and convenience. When you select a link to an outside website, you are leaving the www.iCareHealthPlan.org website.

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