Skip Navigation

繁體中文 EN ESPAÑOL
Review Your Provider Profile
Learn More

Locate a doctor, hospital or other health care services near you.

Search Now

At EmblemHealth we’re dedicated to helping you stay healthy, get well and live better.

Learn More

Learn about EmblemHealth’s pharmacy benefits.

Learn More
Learn More

EDI Transactions: What to Know to Make Them Work for You
(Revised July 25, 2014)

Date Issued: 7/31/2014

Electronic data interchange (EDI) transactions help practitioners manage their practices more effectively. EmblemHealth supports HIPAA compliant electronic data interchange (EDI) transactions. In particular, electronic claim submission provides an easier, faster way to submit claims. Today, tens of thousands of health care practitioners have eliminated paper claims and are submitting electronic claims to EmblemHealth in HIPAA compliant professional provider (837P), institutional provider (837I) and dental provider (837D) EDI claims transaction formats. We invite you to consider how electronic claims and other EDI transactions can benefit your practice.

Some of the advantages of electronic claim submission

  • Quicker claim submission, which means faster reimbursement to you.
  • No paper claims to stock and complete.
  • Simplified record keeping by eliminating lost claims paperwork.
  • Reduced clerical time and the costs to process and mail paper claims.

The pathways for electronic claim submission to EmblemHealth

Providers, both institutional and professional, may use practice management system vendors, billing services or clearinghouses to submit claims and other EDI transactions to EmblemHealth.

Please Note: Practice management system vendors, billing services and clearinghouses offer a variety of EDI solutions to the health care community and charge fees or transaction costs for their services. EmblemHealth does not specifically recommend or endorse any vendor or billing service.

Real Time Eligibility Benefit Inquiry and Response (270-271)

The ASCX12N 270/271 health care eligibility benefit inquiry and response transaction function is available for use. This functionality is designed as a secure electronic tool to verify member health coverage, benefits and member responsibilities, such as deductibles, coinsurance, copays, etc. Transactions work for both single members and for batches of members.

Enrolling to use the 270/271 eligibility benefit inquiry and response transaction is easy. Simply contact your billing vendor or clearinghouse. Inform them you would like to use the CAQH HIPAA-compliant 270/271 eligibility benefit inquiry and response transaction.

How to Submit Electronic Claims

The Health Insurance Portability and Accountability Act (HIPAA) promotes administrative simplification of claims payment through the use of uniform electronic data interchange (EDI) operations. This includes using standardized code sets, unique health identifiers and measures to keep personal health information secure. HIPAA compliance requires the use of these ANSI ASC X12N (Version 5010) EDI transaction standards.

Important Requirements

National Provider Identifier (NPI)

Please contact your practice management system vendor to ensure your software is capturing and correctly populating your NPI in your electronic claims. Otherwise, your claims will be rejected by EmblemHealth.

Revised NPI Requirements for Professional Provider Claims (837P)

  • Billing Provider 2010AA: An NPI is required for health care providers in the United States or its territories.
  • Pay-To Address 2010AB: There is no NPI in the Pay-To Address loop. The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address.
  • Rendering Provider 2310B: Only required when the Rendering Provider information is different from the information carried in Billing Provider Loop 2010AA. If this loop is sent, an NPI is required.
  • Rendering Provider 2420A: Only required when the Rendering Provider information is different from the information carried in the 2310B or 2010AA loops. If this loop is sent, an NPI is required.

Revised NPI Requirements for Institutional Claims (837I)

  • Billing Provider 2010AA: An NPI is required for health care providers in the United States or its territories.
  • Pay-To Address 2010AB: There is no NPI in the Pay-To Address loop. The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address.

Revised NPI Requirements for Dental Provider Claims (837D)

  • Billing Provider 2010AA: An NPI is required for health care providers in the United States or its territories.
  • Pay-To Address 2010AB: There is no NPI in the Pay-To Address loop. The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address.
  • Rendering Provider 2310B: Only required when the Rendering Provider information is different from the information carried in Billing Provider Loop 2010AA. If this loop is sent, an NPI is required.

Payer ID Numbers

GHI PPO: 13551
GHI HMO: 25531
HIP: 55247
Vytra: 22264
ConnectiCare VIP Medicare Advantage: 78375

Health Care Claim Status Request and Response (276-277)

You may use the ASC X12N 276/277 (005010X212E2) health care claim status request and response transaction function. This functionality is designed as a secure electronic tool to look up the claim status for a single member or for batches of members.

Enrolling to use the EDI HIPAA/CAQH 276/277 health care claim status request and response is easy. Simply contact your vendor or clearinghouse. Inform them you would like to begin receiving the CAQH HIPAA-compliant 276/277 health care claim status request and response transaction.

HIPAA Transaction Companion Guides

We have made available transaction-specific companion guides to the ASC X12N Implementation Guides adopted under HIPAA. They contain specifications for electronic transmission to EmblemHealth. The guides can assist your vendor or clearinghouse in the set-up and testing process, as well as complying with EmblemHealth-specific transaction requirements that guarantee smooth and successful EDI transaction responses.

The ASC X12N 270/271 (005010X279A1) Health Care Eligibility Benefit Inquiry and Response Companion Guide and the ASC X12 276/277 (005010X212E2) Health Care Claim Status Request and Response Companion Guide are also available in Claims Corner.

Avoiding Duplicate Claims Submissions

When duplicate claims are submitted, you may actually delay claims processing and can potentially create confusion for the member. You may access duplicate claims submissions at Claims Corner for more information.

Electronic Claim Attachments

Attachments cannot be submitted electronically at this time. However, most claims should be submitted electronically. If supporting documentation is required for the settlement of your claim, we will request the additional information.

Please note: We will be enhancing our technology to support an electronic attachment capability for professional practitioners. We will notify you when we are ready to accept attachments electronically.

Electronic Coordination of Benefits (COB) Claims

Commercial COB claims are not accepted electronically at this time. We are currently enhancing our technology to support this functionality. We anticipate that commercial COB claim acceptance/processing will be available in late fourth quarter 2014. We will notify you when it's available.

GHI PPO, GHI HMO, HIP and VYTRA participate in the national Coordination of Benefits Agreement (COBA) program for the receipt and processing of Medicare Part A and Part B Supplemental crossover claims.

PNC Remittance Advantage Is Good For Your Practice

EmblemHealth offers PNC Remittance Advantage, a no-cost online payment solution that helps your office reduce payment processing expenses and improve cash flow.

With PNC Remittance Advantage, you can receive direct deposits to your bank account(s) (electronic funds transfer) and view or download your remittances online (electronic remittance advice). Electronic transactions are fast, convenient and reduce the risk of lost or stolen payments.

Registering is simple, secure and takes just moments to complete

  1. Have available a recent EmblemHealth Explanation of Benefits (EOB) and either a voided check or a letter from your bank listing the account name, account number, account type and bank routing number for each of your practice’s bank accounts used to receive electronic payments.
  2. Go to PNC Remittance Advantage at https://rad.pnc.com.
  3. Select the “Register for Portal and Online Payment Services” link on the upper left side of your screen.
  4. Register for the website with your email address, your practice’s tax identification number and your Provider ID, found on your EmblemHealth EOB.
  5. For larger practices, add all of your practice’s payees and organize them according to bank account, location, personnel or whatever is appropriate for your practice.
  6. Enter your bank account information and upload a scanned image of your voided check or bank letter.
  7. Associate each payee group with a bank account, and then submit your enrollment form online.
  8. Allow two weeks to validate the bank account information before receiving electronic payments and remittance advices.

If you need help with the registration process, please call the PNC Remittance Advantage Help Line at 1-877-597-5489, option 1, Monday through Friday, from 8:30 am to 8:30 pm (ET).

EDI Help Desk

All inquiries and comments regarding initiation, set-up, submission and support should be directed to our EDI Help Desk at 1-212-615-4362, Monday through Monday through Friday, 9 am to 5 pm (ET).

You are now leaving the Medicare section of the EmblemHealth website.

Click to Continue ×

Your member ID # is on the front of your ID card.

In most cases, if you are the policy holder, you can also use your Social Security Number to register.