How to Submit Claims and Appeals to Coventry Health

What Medical Billers, Physicians, and Patients Should Know

Coventry Health Care operates a number of health plans, insurance companies, and worker's compensation service companies in all 50 states. The company offers a full range of risk and fee-based products to not only individuals and employers but also governments agencies, government-funded groups, and other insurance carriers.

In May 2013, Aetna completed the acquisition of Coventry and today operates the company under the title Aetna Coventry.

Medical billing processes are relatively easy to navigate using Coventry's proprietary web portal. From preauthorization and submissions to corrections and appeals, the integrated system is intuitively designed to facilitate billers. For others, there are tips and insights that can help simplify the process and expedite billing in a timely manner.

Covered Plans

Coventry Health Care is a large, diversified company that offers a variety of plans and products. Here is just a partial list of the plans and companies for whom you make submit claims: 

  • Altius Insurance
  • American Postal Workers Union (APWU)
  • Compass Rose Health Plan
  • Coventry CareLink
  • Coventry Health Care of Delaware, Florida, Georgia, Iowa, Kansas, Louisiana, Nebraska, and Nevada
  • Coventry Health and Life of Oklahoma
  • Coventry Health Care National Network
  • Coventry Missouri
  • First Health Life & Health Insurance Co.
  • First Health Network
  • Foreign Service Benefit Plan
  • Group Health Plan
  • HealthAmerica/HealthAssurance
  • Mail Handlers Benefit Plan
  • PersonalCare
  • Rural Carriers Benefit Plan
  • Southern Health Services
  • Strategic Outsourcing, Inc
  • University of Missouri
  • WellPath

Services Offered

Close up of someone handing a doctor their health insurance card
Frederic Cirou / Getty Images

To access general information on health care billing with Coventry, refer to the Contact Grid located in Section 6 of the Provider Manual.

For customer service calls, refer to the Member Services phone number listed on the member's ID Card. A representation will be able to help you with the following issues:

Eligibility and Benefits

To check whether a procedure or provider is covered (eligibility), how much a product or service is covered (benefits), or what the status of a claim is (claim status):

  • Call the Member Services number on the member's ID card.
  • Log on to the Coventry provider portal.
  • Log on to your Emdeon Office account, which provides revenue and payment cycle management for healthcare professionals.

Preauthorization Requests

A female doctor at her computer
David Leahy / Getty Images

Preauthorization is the process wherein the insurer decides whether a procedure or service is medically necessary. The decision may be based on the type of policy an individual has, the treatment guidelines for the specific disease or medical condition, and/or whether or not the treatment is classified as an Essential Health Benefit (EHB) under the Affordable Care Act. EHBs are a set of 10 categories of services that health insurance providers are required by law to cover. 

Services typically requiring preauthorization include:

  • Hospital inpatient or observation care
  • Certain outpatient surgery
  • Transplants
  • High-cost radiology (such as a CT, MRI, PET, or bone density)
  • Durable medical equipment (DME)
  • Prosthetics or orthotics
  • Home care
  • Pain management
  • Rehabilitation services
  • Fertility and reproductive services
  • Sleep studies

You can submit preauthorization requests through Coventry's provider portal. Electronic preauthorization is available 24 hours a day, Monday through Sunday. Once the preauthorization is submitted, a tracking number will be assigned to the request.

A tracking number does not indicate approval. You will be notified if the request s approved or denied. Approvals will be given a certification ID number.

For specific questions, contact the preauthorization number listed on the member's ID card.

Claims Submission

Insurance claim form on a tablet
Courtney Keating / Getty Images

There are three ways to switch your claims to Coventry Health:

  • Through the Coventry provider portal
  • Through Emdeon Office
  • By mailing the claim to the regional Claim Departments address listed on the member's ID card

Generally speaking, physicians have 90 days from the date of service to submit a claim for payment, while hospitals have up to one year.

Secondary Claims

Secondary claims can be submitted electronically or by mail with the primary payer's EOB. Be sure to include:

  • The adjustment amount at both the claim land service-line level (if available)
  • The reason for the adjustment (such as contractual obligation, deductible, coinsurance, or others) using the codes furnished by the primary payer's remittance
  • The primary payer's paid amount at both the claim level and service-line level (if available)

Always be sure to double-check the claims filing limit in the Provider Agreement since the timeframe can sometimes vary by the plan, service category, or Coventry subsidiary.

Claims Correction

Corrected claims should be submitted electronically by updating the Claim Frequency Code (CFC) on the provider portal or Emdeon Office account. Always be sure to include the correct billing code and indicate the changes with the following Bill and Frequency Type (BFT) codes:

  • 7 = Replacement of a prior claim
  • 8 = Void/cancel a prior claim

Upon receipt of the corrected claim, Coventry will recover the overpayment and advise you of the adjustment on an electronic remittance advice (ERA).

If there is a health insurance overpayment, Coventry will recoup the amount. This will be outlined on an ERA with a reversal of the incorrect adjudication followed by the corrected adjudication.

Refunds of existing credit balances can be sent to the address listed on the Contact Grid in Section 6 of the Provider Manual.

Filing an Appeal

To appeal a denied claim, complete the Complaint and Appeal Request form on the provider portal or request a copy from a Member Services representative on the member's ID card.

When submitting the appeal, be sure to include:

  • The Complaint and Appeal Request form
  • A copy of the denial letter or EOB letter
  • The original claim
  • Reasons why you think the denial should be reversed
  • Any supporting documents (such as medical records, lab tests, or doctor notes)

Documentation can be sent by post to Coventry Provider Resolution Team, P.O. Box 14020, Lexington, KY 40512. The national fax number is 1-859-455-8650.

Your Legal Rights

Under the law, you have the right to appeal a health insurance company’s decision to deny payment for a claim or terminate your health coverage. The rules apply to health plans created after March 23, 2010 and to older plans that have been changed in certain ways since that date.

Health plans that started on or before March 23, 2010 may be "grandfathered health plans." The appeals and review rights do not apply to them.

Phases of Appeal

Depending on the phase of the appeal, you should receive a response within the following timeframe:

  • For the initial reconsideration phase, you should receive a decision within 3 to 5 days. If a specialty review is needed, the decision can take as long as 60 days.
  • For the secondary appeals phase, which occurs if the initial reconsideration is denied, expect a decision within 60 days.
  • For urgent appeals, in which the denial of service can place a patient's health at risk, a response will be returned within 36 to 72 hours.
  • For an external review, which can be requested if the secondary appeal is denied, expect a response within 30 days.

By law, your health insurer must provide information on how to request an external review on policies that began on or after July 1, 2011.

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Article Sources

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  1. Hutchins VA, Samuels MB, Lively AM. Analyzing the Affordable Care Act: essential health benefits and implications for oncology. J Oncol Pract. 2013;9(2):73-7. doi:10.1200/JOP.2012.000881

  2. Department of Health and Human Services. Appealing Health Plan Decisions. Updated January 31, 2017.