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  • Claims > Important Requirement for Electronic Claims Submission

    National Provider Identifier

    Please contact your practice management system vendor to ensure your software is capturing and correctly populating your National Provider Identifier (NPI) in your electronic claims or your claims will be rejected by EmblemHealth. Please note the following NPI requirements for electronic health care claim submissions:

    Professional Provider Claim (837P) NPI Requirements

    • 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.

    Institutional Claim (837I) NPI Requirements

    • 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.

    Dental Provider Claim (837D) NPI Requirements

    • 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.

      Payor ID Numbers

      Plan Payer ID

      GHI HMO

      25531

      GHI PPO

      13551

      HIP

      55247

      Vytra

      22264

       CCI VIP Medicare Advantage 78375

        Avoiding Duplicate Claims Submissions

        When duplicate claims are submitted, you potentially delay claims processing and create confusion for the member. You may read more about how to avoid duplicate claims submissions at Claims Corner on www.emblemhealth.com.

        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 it. One common request is for the Unlisted Procedure or Service Code Form.

        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.

        Claims Submission for Unlisted Procedure or Service Codes
        In accordance with American Medical Association Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) reporting guidelines, please use the Unlisted Procedure or Service Code Form available at www.emblemhealth.com to submit claims for unpublished procedure or service codes. This information will be used to determine appropriate payment and claim adjudication in conjunction with the member's benefit plan.

        Electronic Coordination of Benefits Claims

        At this time, commercial electronic coordination of benefits claims are not accepted electronically. We are currently enhancing our technology to support this functionality. We anticipate that commercial COB claim acceptance/processing will be available late fourth quarter 2014. We will notify you when it’s available.

        EmblemHealth PPO and HMO 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 Funds Transfer and Electronic Remittance Advice for EmblemHealth Claims

        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 accounts (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.

        The registration process is simple and secure and takes just moments to complete:

        • Step 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.
        • Step 2:  Go to PNC Remittance Advantage at https://rad.pnc.com.
        • Step 3:  Select the “Register for Portal and Online Payment Services” link on the upper left side of your screen.
        • Step 4:  Register for the website with your email address, your practice’s tax identification number and your Provider ID, found on your EmblemHealth EOB.
        • Step 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.
        • Step 6:  Enter your bank account information and upload a scanned image of your voided check or bank letter.
        • Step 7: Associate each payee group with a bank account, and then submit your enrollment form online.
        • Step 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).

        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 and copays. 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.

        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.

        EDI-Related Help Desk Support

        Please call 1-212-615-4362, Monday through Friday, from 9 am to 5 pm for EDI-related Help Desk Support or questions about HIPAA EDI transactions.

        CMS 1500 And UB04 Forms

        To obtain UB04 and CMS 1500 forms, sign in to Health Forms and Systems, Inc. at www.health-forms.com or the Centers for Medicare & Medicaid Services at www.cms.hhs.gov/CMSForms/CMSForms/list.asp. UB04 and CMS 1500 forms are also available in Claims Corner on www.emblemhealth.com.

        Hard copy forms can be requested by calling the U.S. Government Printing Office at 1-800-869-6590 or 1-202-512-1800.

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        Glossary terms found on this page:

        An activity of EmblemHealth or its subcontractor that results in:

        • Denial or limited authorization of a service authorization request, including the type or level of service
        • Reduction, suspension or termination of a previously authorized service
        • Denial, in whole or in part, of payment for a service
        • Failure to provide services in a timely manner
        • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

        The process by which a claim is paid or denied based on eligibility and contract determination.

        A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.

        Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

        An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

        The government agency responsible for administering the Medicare and Medicaid programs.

        When a member is covered by more than one benefit plan, with both providing similar benefits, EmblemHealth coordinates with the other carrier to ensure appropriate reimbursement. Also called Coordination of Benefits.

        A percentage of the allowed charge that is payable by the member, not EmblemHealth, for covered services rendered by an out-of-network provider. After the member has met his or her deductible, EmblemHealth will pay a percentage of the allowed charge for those covered services in accordance with the member's benefit program. The member is responsible to pay the remaining percentage of the allowed charge. This remaining percentage is the coinsurance charge.

        When a member is covered by more than one benefit plan, with both providing similar benefits, EmblemHealth coordinates with the other carrier to ensure appropriate reimbursement. Also called COB.

        The fixed dollar amount members must pay for certain covered services. It is generally paid to a network provider at the time the service is rendered.

        A portion of eligible expenses that an individual or family must pay during a calendar year before EmblemHealth will begin to pay benefits for covered services.

        A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

        A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment and the claims appeal process. Also called Explanation of Benefits.

        A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

        A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment and the claims appeal process. Also called an EOB.

        A professionally licensed individual, facility or entity giving health-related care to patients. Physicians, hospitals, skilled nursing facilities, pharmacies, chiropractors, nurses, nurse-midwives, physical therapists, speech pathologist and laboratories are providers. All network providers are health care providers, but not all providers are network providers.

        A federal act that protects people who change jobs, are self-employed or have pre-existing medical conditions. The act standardizes an approach to the continuation of health care benefits for individuals and members of small group health plans and establishes parity between the benefits extended to these individuals and those offered to employees in large group plans. The act also contains provisions to ensure that prospective or current enrollees in a group health plan are not discriminated against based on health status and protects the confidentiality of protected health information of members. Also known as the Health Insurance Portability and Accountability Act.

        An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.

        A unique number which identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as Member ID Number.

        A unique number that identifies the member's enrollment with EmblemHealth. EmblemHealth's claims are processed by this number. Also known as Member ID Number.

        An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

        Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

        A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

        A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

        An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program. Also known as MA.

        This part of Medicare provides benefits for hospitalization, extended care and nursing home care to Medicare beneficiaries with no premium payment for qualified individuals.

        An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

        A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

        A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

        A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

        • Doctor of medicine
        • Doctor of osteopathy
        • Dentist
        • Chiropractor
        • Doctor of podiatric medicine
        • Physical therapist
        • Nurse midwife
        • Certified and registered psychologist
        • Certified and qualified social worker
        • Optometrist
        • Nurse anesthetist
        • Speech-language pathologist
        • Audiologist
        • Clinical laboratory
        • Screening center
        • General hospital
        • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

        A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

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