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• Place of service code
• NPI number
• Type of service
• Days and units
• Anesthesia time in minutes
• Include the following information for all injectible drugs:
1. Average Wholesale Price (AWP) reimbursed Providers - the National Drug Code (NDC)
Number and the NDC unit(s) associated with each drug.
2. Average Sale Price (ASP) reimbursed Providers – the applicable HCPCS code and HCPCS
unit(s).
Institutional Claims
• Bill type
• Revenue codes and HCPCS codes
• Patient status code
• DRG code
• All appropriate diagnostic codes
• All appropriate diagnosis codes (ICD9-CM codes)
• Detailed billing for all pharmacy related revenue codes. The detailed billing should include the
name of the drug, the National Drug Code (NDC) number and the units associated with each
drug.
• Skilled nursing facilities should include a description of charges, for example, bed level, blood
glucose draw/stick, occupational/physical/speech therapy and radiology. Specific CPT-4 Codes
are also required based on the services rendered.
• NPI Number
Claims must be submitted with all required information within 180 days of the date on which the
service was rendered. All claims submitted after the 180-day period will be denied for untimely filing.
For claims questions, please contact Provider Services at 1-888-353-3789. A Provider Service
Representative will be able to answer your questions concerning eligibility, benefits and claims. If a
claim needs to be reprocessed for any reason, the Provider Service Representative will work with the
Claims Department to handle these cases.
Providers who are being paid under capitation and expect no additional payments still must submit
claims in order to capture encounter data as required per your Bravo Health Provider Agreement. This
encounter data should be submitted to Bravo Health’s Claims Department.
If a Provider provides services that require prior authorization, without obtaining prior authorization, the
claim for those services will be denied.
If appropriate, Providers must include the following additional attachments to their claim
submission:
• If Bravo Health is the secondary payer, the primary payer’s Explanation of Payment
• For Institutional Claims a itemized bill for pharmacy charges or claims exceeding stop loss thresholds.
