Claim Payment Procedures

SWCAA shall pay the Provider only for services specifically authorized by SWCAA. SWCAA accepts no financial liability for services rendered and/or fees due to the Provider other than those services specifically authorized on SWCAA’s service order forms. No payment shall be made for services reimbursed by other funding sources or services which are in excess of Medicaid, Medicare, or other third party agreements except as expressly stated in advance on SWCAA service orders. Provider shall refund to SWCAA any payments for services rendered and/or fees paid to the Provider, pursuant to the terms of this Agreement that are subsequently paid for by any such third party funding source.

The Provider shall submit claims (2 copies) for authorized services rendered to SWCAA clients on forms HCFA-1500 or in an electronic format approved by SWCAA. Billing instructions for completion of the HCFA-1500 form are contained in Billing Instructions for HCFA-1500 Form. Electronic submission should be done with the latest version of the Provider Electronic Solutions software which can be downloaded for free from www.ctdssmap.com. The submitted claims must be accompanied by hard copy printouts. Such claims may be submitted twice a month for services rendered for the period of the 1st through the 15th, and for the 16th through the last day of each month, but no later than within thirty days of the last day of the month in which services were rendered unless otherwise authorized by SWCAA. Payment of claims is subject to approval by DSS. The following link will give providers a SWCAA Electronic Claim Cutoff Date Calendar. This will be updated every 6 months with EDS Electronic Claim Cutoff Transmission dates as available. 

Corrected claims or delayed claims submitted beyond six months of service delivery dates will be denied payment. When a Letter of Correction is sent to the provider, the correction to the claim should be completed. The new claim and a copy of the letter should be returned to the Finance Department within 15 days of receipt. The claim will then be processed for payment. Up to this point the claim has not been processed for payment by EDS.

When adjustments need to be made to a paid claim, a PCAR form is created for this purpose. It is filled out with all information relevant to the claim change according to the PCAR Instructions (Paper or Electronic) and returned to the Finance Department to audit and forward to EDS.

When a provider determines from the Remittance Advice that a claim has not been processed or has denied with an EOB code that requires further action, please use the SWCAA Claim Inquiry Worksheet.This is in a PDF format and downloadable from this website. It contains all the pertinent information that is required for the SWCAA Finance department to research each claim thoroughly. Our goal is to make the claim inquiry process comprehensive and timely.

The worksheet can then be mailed or faxed (203‐696‐3866) to the SWCAA Finance department to research further. 
 
Claims for services that SWCAA clients do no utilize or refuse to utilize will be denied. The Provider agrees to collect any amounts due to the Provider from SWCAA clients based on cost sharing agreements between SWCAA client and SWCAA. No other charges will be billed by the Provider to either the client or SWCAA. There may be no solicitation of additional donations/contributions from the client by the Provider. The Provider shall have a formal Conflict of Interest Policy which prohibits employees from solicitation or acceptance of gifts, gratuities, or donations from clients.

Claims for services that were not included in the SWCAA client’s plan of care or service authorization, or which exceed the amounts authorized will be denied. Claims for services which have been canceled by SWCAA, by phone or in writing, will be denied payment.

Claims for services which the Provider fails to submit an accurate and complete invoice or fails to maintain appropriate documentation that the service was delivered may be denied payment.