23
Routine Within 4 weeks of the referral
Availability Standards
PCPs OB/GYNs Behavioral Health Providers
1 Provider for every 500 Members 1 Provider for every 2500
Members
1 Provider within 20 miles/minutes to
Member
1 Provider within 20 miles to
Member
1 Provider within 20 miles to
Member
1 Provider within 30 miles/minutes to
Member
1 Provider within 30 minutes to
Member
1 Provider within 30 minutes to
Member
CLAIMS SUBMISSION
While Bravo Health prefers electronic submission of claims, both electronic and paper claims are accepted.
Please see quick reference guide for details (page 3).
Bravo Health pays Clean Claims according to contractual requirements and CMS guidelines. A Clean
Claim is defined as:
A claim for a Covered Service that has no defect or impropriety. A defect or impropriety includes,
without limitation, lack of data fields required by Bravo Health or substantiating documentation, or
a particular circumstance requiring special handling or treatment, which prevents timely payment
from being made on the claim. The term Clean Claim shall not include a claim from a Provider that
is under investigation for fraud or abuse regarding that claim. The term shall be consistent with the
Clean Claim definition set forth in applicable federal or state law, including lack of required
substantiating documentation for non-Participating Providers and suppliers, or particular
circumstances requiring special treatment that prevents timely payment from being made on the
claim. If additional substantiating documentation involves a source outside of Bravo Health, the
claim is not considered clean.
The following standard CMS-required data elements must be present for a claim to be considered a Clean
Claim. This applies to both electronic and paper claims:
Professional Claims
• Patient name
• Patient demographic information
• Member identification number
• Rendering Provider name
• Payee name and address
• Provider signature
• Explanation of Benefits from the primary carrier when Bravo Health is the secondary payor
• If the services were not rendered in an office or home setting, list the name and address of the
facility where services were rendered in Box 32
• Provider federal tax identification number
• Date of service
• All appropriate diagnosis codes (ICD9-CM codes)
• Procedure code for each service rendered (CPT-4 or HCPCS Codes)
• All appropriate modifiers for each service rendered
• Amount billed for each procedure
