HealthChoices Coverage and Billing
In the State of Pennsylvania, providers are required to bill private health insurance for the costs associated with ASD for children under the age of 21, per the PA Act 62 Mandate. The PA Act 62 Mandate does not apply to private health insurance outside of Pennsylvania or self-funded, ERISA, or group policies of 50 employees or less. The maximum amount private health insurance is required to pay as a result of the PA Act 62 Mandate is adjusted annually. Providers are required to verify eligibility, benefits, and cap amount each time an ASD member presents. Providers are required to bill Community Care according to the instructions outlined in the Community Care Billing Manual. ASD claims are those claims billed with a primary ASD diagnosis. Community Care requires providers include the explanation of payment (EOP) from the private health insurance with each ASD claim. In the event a policy cap is exhausted, providers must include the exhaustion letter with each claim. Please refer to the Billing Manual in Community Care’s Provider Manual for billing instructions.