The following billing information is designed to assist providers with specific guidelines for submitting claims to the Health Care District's District Cares program. Please see the Claims/Billing section of the Provider Handbook for additional information.
All claims must be submitted to the Health Care District within one hundred and eighty (180) days from the date of service. Claims are reimbursed in accordance with contract provisions and rates. Any service not properly authorized or not considered a covered service under the benefit plan shall be denied reimbursement.
Claims shall be submitted for payment on standard claim forms. The CMS-1500 form shall be utilized for all non-institutional services and the UB-04 for institutional services. You may also submit professional claims on a Health Insurance Portability Accountability Act (HIPAA) compliant X12 electronic file upon completion of Electronic Data Interchange (EDI) testing with the Plan. If applicable, a copy of the referral form and/or authorization reference number should be attached to the claim.
We strongly encourage you to consider submitting your claims electronically via Electronic Data Interchange (EDI). Submitting claims via EDI can significantly reduce your handling and postage costs. Also, submissions save on office expenses such as forms, staff preparation and follow-up. It is HIPAA compliant via a secured connection, offers claims receipt confirmation and is available seven (7) days a week.
See the Electronic Data Interchange section for more information.
Mail all District Cares paper claims to the following address:
Health Care District of PBC
1515 N. Flagler Dr., Suite 101
West Palm Beach, FL 33401-3429
The Health Care District shall make payment on all properly documented “clean” claims within sixty (60) days of receipt. A check accompanied with a remittance advice will be mailed to the providers for reconciliation of payments. Payments, denials and claims requiring additional information are documented on the remittance advice. All denials include a “denial reason code” on the remittance advice. An explanation of all codes will appear on the last page of the remittance advice.
Payments made by the Health Care District of Palm Beach County are considered in full for services rendered. Providers may not balance bill any members of the District Cares program for any covered service. This is outlined in the provider agreement under Compensation.
Member Financial Responsibility
Members will bear full financial responsibility for payment of all charges for services for the following:
- Non Covered services
- Covered services provided by a non-participating provider or facility
- Services provided beyond the member’s benefit maximum
Billing for Non-Covered Services
Provider shall not, either directly or indirectly, bill, charge, or seek compensation from Members for Covered Services rendered; provided, however, that nothing herein shall be construed to prohibit Provider from collecting or pursuing collection of Program authorized Copayments or charges for non-Covered Services or seeking payment from other Payors. Prior to providing non-Covered Services to a Member, Provider shall:
- Inform the Member that the services to be provided are not Covered Services;
- Inform the member that Program will not pay or be liable for such services;
- Inform the Member that if Provider is seeking compensation for such services, the Member shall be financially liable for such services;
- Provide to the Member, the form agreement on Addendum E (PDF) hereto and obtain such agreement, once fully executed, from the member.
In the event Provider does not fully comply with items (1) – (4), the Member shall not be liable to