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Providers ยป Claims & Billing

Claims Submission Guidelines

Claims Guideline and Submission

SWHP accepts both paper and electronic claims. However, electronic claim submission is highly recommended as our providers can expect faster responses and more timely payments. There is no charge for EDI submission directly to SWHP.

Filing Deadline
All claims, regardless of submission format, must be received in our office within 95 days of the date of service. COB claims must be submitted within 95 days of the primary payer's EOP date. Claims not received within the filing deadline will be denied. Please note that members cannot be billed for claims denied by SWHP for filing deadline. See the provider reimbursement section for further details.

Clean claims are claims submitted via standard electronic or paper formats within the specified filing deadline. Clean claims do not require SWHP to investigate, develop or acquire additional information from the provider or other external sources.
Clean claims should have

  • All required fields populated with the appropriate information and industry standard codes
  • No defect or impropriety
  • No particular circumstance requiring special treatment that prevents timely payment from being made, including any lack of required, substantiating documentation.
  • No handwritten information

Non-clean claims are defective claims or submitted claims that lack the required TDI information necessary for claims processing. Please see the required field table.

Non-clean claims will be rejected and returned to the provider with a letter explaining the reason for the rejection. These claims are considered never received and must be corrected and returned within the filing deadline for processing.

Clean Claim Requirements
The following information is required for a clean claim to be accepted for processing. These requirements apply to both electronic and paper submission:

  • Full patient name
  • Patient's date of birth
  • Valid SWHP member identification number (11-digit number)
  • Complete service level information
    • Date of service.
    • Industry standard diagnosis codes
    • CMS defined industry-standard place of service codes
    • Industry standard procedure codes (e.g., CPT, HCPCs)
    • Charge information and units.
  • Service provider's name, address and National Provider Identifier (NPI)
  • Provider's federal tax identification number (TIN)
  • Only one servicing provider per claim
  • All claim forms must be computer generated or typed. No handwritten claims or corrections will be accepted.
  • All mandatory fields must be complete and accurate.
  • Claim form information changes/corrections using white-out will not be accepted
  • No highlighted information is permitted on a claim form

Missing or incomplete information will result in a claim being returned to the provider. To satisfy SWHP's filing limit policy, returned claims must be corrected and accepted into the claims payment system no later than 95 days from the date of service.