Claims Corner is your resource
EmblemHealth implemented claims policy and coding guideline changes over the past year. Below is a summary of the posted updates. Be sure to check the Claims Corner section of our provider webpage for the latest updates. Information that previously appeared in the Utilization Management section has been moved to Clinical Corner. Staying current helps ensure a smooth claims process and can help increase timely payments. Note: Information that previously appearing in the Utilization Management section has been moved to Clinical Corner.
Appropriate use of modifiers
EmblemHealth follows the AMA coding guidelines and policies in accordance with CMS on the appropriate use of modifiers. EmblemHealth will deny the use of a modifier when outside of these guidelines.
- Medical Policy Coding Changes for Ocular Photo screening and Otoacoustic Emission Testing
- Modifier 25 or Modifier 59 must be appended to HCPCS codes G0442 - G0447 when reported with an unrelated Evaluation and Management (E/M) service.
- Modifier QW (CLIA waived test) can only be appended to procedures designated as CLIA waived tests on the clinical laboratory fee schedule.
- Non-physician practitioner claims will be denied if submitted on the same date of service as a physician claim, and when the primary diagnosis on the submitted claims match on the first three characters of any ICD10 regardless of Provider ID and specialty. See: Duplicate Claims from a Non-Physician Practitioner.
EmblemHealth updated its coding policies based on CMS guidance for:
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Evaluation and Management (E/M) Services with Pulmonary Diagnostic Procedures
- Electroencephalogram (EEG)
- Fundus Photography
- Pilonidal Cyst or Pilonidal Sinus
- ClaimsXten billing and reimbursement updates made in 2019: Policy
The following policies were revised:
- Respiratory Assist Devices (RAD), Airway Pressure Devices, and Oral Appliances/Devices
- Inpatient transfers between acute care hospitals/facilities
- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
- Payment policies for Surgical Pathology CPT Codes
The EmblemHealth timely filing time frame is now 120 days unless the participation agreement states an alternative time frame should be applied. See the EmblemHealth Provider Manual for full policy.
When submitting anesthesia claims in the 837P HIPAA Transaction, use qualifier ‘MJ’. Reimbursement will be calculated based on the time submitted.
Enroll in our free electronic funds program
PNC Bank handles electronic funds transfer and electronic remittance advice (ERA or 835) for EmblemHealth. Our PNC Remittance Advantage Program offers paperless claim payments and electronic remittances for free. Electronic transactions are fast, convenient, and lower the risk of lost or stolen payments. PNC Remittance Advantage combines direct electronic funds transfer payments with 835 electronic remittance advice.
Go to rad.pnc.com to enroll. If you need help, call 877-597-5489. You will need your provider ID number to enroll. You can find it on your paper remittance.
Enroll in our free electronic funds transfer program
Our PNC Remittance Advantage Program offers paperless claim payments and electronic remittances for free. Electronic transactions are fast, convenient, and lower the risk of lost or stolen payments. PNC Remittance Advantage combines direct electronic funds transfer payments with 835 electronic remittance advice. Go to rad.pnc.com to enroll. If you need help, call 877-597-5489. You will need your provider ID number to enroll. You can find it on your paper remittance.
For our ASO members who access our Bridge Network, separate registration is needed with PNC’s company ECHO Health. Payments through ECHO follow a different workflow than those which may be in place with ECHO’s parent company PNC. EFT elections must be made for ECHO even if in place for other EmblemHealth claims payments. See the Bridge Network Members and New Claims Payment Process for information on all payment options. If you have questions regarding your payment options, please contact ECHO at 888-492-0032.
TriZetto is our preferred electronic data interchange source
EmblemHealth and Cognizant Healthcare Services, LLC have teamed up to allow providers to submit electronic claims through Cognizant’s TriZetto Provider Solutions (TPS). EmblemHealth’s preferred electronic data interchange (EDI) connection is TPS. If you would like to connect directly to TPS for free, please complete the form. If you already use a clearinghouse, such as Ability, SSI, Availity, or ClaimLogic, your claims will be sent to EmblemHealth. There will be no changes and you do not need to complete the form.
Make sure you have your correct NPI on file
Sign in to your provider profile on emblemhealth.com to make sure you have the right National Provider Identifier (NPI) on file. Using an incorrect NPI can result in denied claims. Federal law mandates that health care practitioners use their unique, 10-digit NPI when submitting standard electronic health care transactions, such as claims.
Taxonomy codes are important
Remember to provide taxonomy codes on all EmblemHealth claims. The absence of these codes may result in incorrect payments or the inability of your patients to fill their prescription.
Taxonomy codes are administrative codes that identify health care professionals at both the individual practitioner and organizational level. These codes include information on the practitioner’s specialty.
- You must register all taxonomy codes – Taxonomy codes are self-reported by registering with the National Plan and Provider Enumeration System (NPPES) and by claims submission. Taxonomy codes may be obtained by visiting the National Provider Identifier Registry website. It is critical to register all applicable taxonomy codes with the NPPES and to use the correct taxonomy code to assist EmblemHealth in the timely and accurate processing of claims.
- How to submit taxonomy codes on your claims: Taxonomy codes on electronic claim submissions with the ASC, X12N, 837P, and 837I format are placed in segment PRV03 and loop 2000A for the billing level, and segment PRV03 and loop 2420A for the rendering level. For paper CMS-1500 professional claims, the taxonomy code should be identified with the qualifier “ZZ” in the shaded portion of box 24i. The taxonomy code should be placed in the shaded portion of box 24j for the rendering level, and in box 33b preceded with the “ZZ” qualifier for the billing level.