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EDI Transactions: What to Know to Make Them Work for You
(Revised July 22, 2013)

Date Issued: 8/8/2013

Electronic data interchange (EDI) transactions help practitioners manage their practices more effectively. EmblemHealth supports HIPAA compliant electronic data interchange (EDI) transactions. 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

  • Practice management system vendors, billing services and practitioners that submit claims and other EDI transactions via Emdeon Business Services.
  • Practice management system vendors, billing services and institutional practitioners that submit claims and other EDI transactions directly to EmblemHealth.

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

How to Submit Electronic Claims

Revised for HIPAA 5010 Compliance

HIPAA has adopted new guidelines for electronic health care transactions. The Version 5010 rules for transactions became effective on January 1, 2012, and EmblemHealth is compliant as of that date. Compliance with HIPAA requires the use of ANSI ASC X12N (Version 5010) transaction standards and implementation guides.

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

Questions?

If you or your system vendor has any questions regarding the above EmblemHealth NPI technical requirements, please contact the EDI Operations Call Center at 1-212-615-4362.

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.

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 during the second quarter 2014, and 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.

Electronic Remittance Advice (ERA)

The Electronic Remittance Advice (ERA), HIPAA 835 transaction is available for GHI PPO, GHI HMO and HIP professional and institutional practitioners through Emdeon Business Services. Enrollment is required at both Emdeon and EmblemHealth in order to receive electronic remittance advice (ERA). If you use a practice management system or hospital information system vendor, please have them enroll with Emdeon (if they have not already done so) to receive the ERA.

EDI-Related Support

Please call 1-212-615-4362,Monday through Friday, 9 am to 5 pm, for any questions you may have. For questions related to the HIPAA EDI transactions, you may also contact our EDI Operations Call Center at 1-212-615-4362.

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