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Claims and Payment

We utilize best practices to ensure timely and accurate payment to our network providers.

Claims can be submitted using one of the following options:

  • Provider Secure Portal
  • Clearinghouses: EDI Payor ID 68069
  • Mail Paper claims to the appropriate Claims Submission Addresses found in the accordions below

CMS HCFA -1500 Claim Form
The CMS 1500 claim form is used to bill for most non-facility services, including professional services, transportation, and durable medical equipment. Ambulatory surgical centers and independent laboratories also must bill for services using the CMS 1500 claim form. FQHC services may also be billed on a CMS 1500 claim form.

CMS HCFA -1500 Claim Form (PDF)

UB-04 Claim Form
The UB-04 claim form is used to bill for all hospital inpatient, outpatient, and emergency room services. Dialysis clinics, nursing homes, free-standing birthing centers, residential treatment centers, and hospice services also are billed on the UB-04 claim form. Claims for IHS and Tribally owned and/or operated 638 facilities, requesting reimbursement at the All-Inclusive Rate (AIR) are also submitted on the UB-04.

UB-04 Claim Form (PDF)

Corrected Claims Submissions

Clean claim resubmissions must be received no later than 12 months from the date of services or 12 months after the date of eligibility posting, whichever is later.

A corrected claim is one that may have been denied for:

  • Needing additional information
  • Incorrect date of service
  • Timely filing
  • Incorrect procedure code/modifier
  • Age/gender, age/procedure
  • Number of units
  • Bill type

To resubmit a corrected EDI claim, the Claim Frequency code (3rd character in the bill type) in the 2300 loop CLM05-3 segment should be populated with a '7' to indicate replacement of previous claim. The original Arizona Complete Health generated claim ID, if known, should be sent in the 2300 CLM loop with a REF segment with an F8 qualifier.

To resubmit on paper, corrected claims must be appropriately marked as such. For a UB04, the 3rd digit of the bill type in Box 4 should indicate a '7' as a replacement of previous claim. The Arizona Complete Health generated claim ID in Box 65 labeled Payer Claim ID. For CMS1500 submission, the claim resubmission code in Box 22a should contain a '7' for replacement of previous of claim and the original Arizona Complete Health generated claim ID should be sent in Box 22b labeled the Original Ref number.

Initial paper claim submissions and paper claim resubmissions must be sent to:

Arizona Complete Health-Complete Care Plan
P.O. Box 9010
Farmington, MO 63640-9010

Effective 3/1/2019: Timely Filing: 120 Days
Prior to 3/1/2019: Timely Filing: 180 Days


Allwell from Arizona Complete Health
P.O. Box 9030
Farmington, MO 63640-9030

Timely Filing: 95 Days

Ambetter from Arizona Complete Health
P.O. Box 9040
Farmington, MO 63640-9040

Timely Filing: 120 Days