EmblemHealth Guide for Electronic Claims Submissions

Electronic data interchange (EDI) transactions provide an easier, faster way to submit and review claims. EmblemHealth supports Health Insurance Portability and Accountability Act (HIPAA)-compliant EDI transactions. We invite you to consider how electronic claims and other EDI transactions can benefit your practice or facility.

Advantages of Electronic Claims Submission

  • Less expensive: No more paying to process and mail paper claims.
  • Quicker claims submission, and faster reimbursement to you. 
  • No paper claims to stock and complete.
  • No more lost claims paperwork.
  • Simplified record keeping. 
  • Reduced administrative burden, freeing up your staff for other tasks.

Pathways for Electronic Claims 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.

 

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. 

TriZetto: Our Preferred Electronic Data Interchange (EDI) Source

EmblemHealth and Cognizant Healthcare Services, LLC (a subsidiary of Cognizant Technology Solutions) are partners. Part of that business venture includes encouraging our providers to submit electronic claims through Cognizant’s TriZetto Provider Solutions (TPS). TPS — a Cognizant Company — is more than just a clearinghouse. It provides exceptional service by combining enhanced provider solutions with superior client support. EmblemHealth’s preferred EDI connection is TPS. If you would like to connect directly to TPS for free, please complete this form. If you already use a clearinghouse, such as Ability, SSI, Availity, or Claim Logic, your claims will be sent to EmblemHealth. There will be no changes and you do not need to complete the form.

 

For more information, please email ttpssupport@trizetto.com.

Helpful Tips for Proper Setup of Electronic Billing Systems

  • Avoid duplicate claims submissions.
    • Allow a reasonable amount of time to complete your account receivable reconciliation process. 
    • Ensure your billing system is not set up to automatically re-bill every 30 days.
    • Ensure your billing system does not automatically generate a paper claim. This duplicate billing practice is costly, can delay processing, and can potentially create confusion for the member.
  • Many times, payment for an original claim is applied to the copay, or the service is denied for medical necessity, eligibility, or another reason. Make sure your automated billing system accurately posts patient responsibility data and claims settlement messages.

How to Submit Electronic Claims

HIPAA promotes administrative simplification of claims payment using uniform EDI operations. This includes using standardized code sets, unique health identifiers, and measures to keep personal health information (PHI) secure. HIPAA compliance requires the use of these ANSI ASC X12N (Version 5010) EDI transaction standards.

Payer ID Numbers

See our Claims Contacts for current Payer IDs.

Member ID Numbers

To protect our members’ PHI, do not use a member’s Social Security number when transmitting electronic claims. HIPAA-protected information is relayed and used for the proper adjudication of electronic claims and benefits for EmblemHealth members. Such PHI is confidential. Instead, please use the member's ID number, which can easily be obtained from the member’s ID card or our provider portal.

 

Electronic claims submitted to EmblemHealth that include a member’s Social Security number instead of the member’s ID number will be rejected. 

NPI & Taxonomy Requirements

National Provider Indentifier (NPI)

Contact your practice management system vendor to ensure your software is capturing and correctly populating your NPI in your electronic claims or EmblemHealth will reject your claims. The NPIs for every servicing provider on a submitted claim must be populated. Note the following NPI requirements for electronic health care claim submissions:

Professional Provider Claim (837P) NPI Requirement

  • 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.
Taxonomy Codes: Definition and Claims Use

Taxonomy codes are administrative code sets for identifying health care practitioner type and area of specialization. Each taxonomy code is a unique 10-character alphanumeric code that enables practitioners to identify their specialty at the claim level. Taxonomy codes are assigned at both the individual practitioner and organizational practitioner level.

 

Taxonomy codes have three distinct levels: 

  • Level I: Provider Type
  • Level II: Classification
  • Level III: Area of Specialization

A complete list of taxonomy codes can be found within HIPAA. Taxonomy codes are self-reported, both by registering with the National Plan and Provider Enumeration System (NPPES) and by electronic and paper claims submission.

Taxonomy codes registered with NPPES at the time of NPI application are shown on the confirmation notice document received from NPPES with the provider’s assigned NPI number. Current taxonomy codes registered, including any subsequent changes, may be obtained on an inquiry basis by visiting the NPI Registry

 

A practitioner can have more than one taxonomy code due to training, board certifications, etc. It is critical to register all applicable taxonomy codes with NPPES and to use the correct taxonomy code to represent the specific specialty when filing claims. This assists EmblemHealth to quickly and accurately process claims.

 

Taxonomy codes must be included on all HMO claims to avoid incorrect payment.

 

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.

 

Refer to The Importance of Accurate Taxonomy Codes for tips on selecting the correct taxonomy code.

Electronic Claims Attachments

Attachments cannot be submitted electronically at this time. We are enhancing our technology to support an electronic attachment capability for professional practitioners. We will notify you when we are ready to accept attachments electronically. If supporting documentation is required for the settlement of your claim, we will request it. 

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, use the Unlisted Procedure or Service Code Form (PDF download) available on the Provider Toolkit to submit claims for unpublished procedure or service codes. This information is used to determine appropriate payment and claim adjudication in conjunction with the member’s benefit plan.

Electronic Coordination of Benefits Claims

EmblemHealth accepts electronically submitted claims for payment as a secondary insurance carrier, except for commercial coordination of benefits claims. The HIPAA ASC X12N 837 transaction applies to services rendered by health care professionals, including 837P for medical practitioners, 837D for dental practitioners, and 837I for facilities and hospitals in which payment responsibility is apportioned between the primary insurance carrier and a second carrier.

 

Our ability to accept Coordination of Benefit (COB) claims electronically improves the overall processing of claims payments. Electronic COB claims will:

  • Allow for prompt review and payment
  • Ensure fewer claims are denied for missing COB information
  • Reduce human error
  • Be available to HMO and PPO providers at all levels of technological readiness

Accepting electronic COB submissions is another means to improve the efficacy of our claims adjudication. Correct submission of electronic claims to EmblemHealth will also ensure we can process your claims more quickly and accurately. COB electronic claims that do not meet the requirements set forth in the 5010 Implementation Guides or are submitted without the necessary information about the other payer may be rejected for missing, incomplete, or invalid information.

 

We 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.

Medicare PPO Electronic Claims Submission

You (the clinician, provider group, facility, etc.) must submit an electronic claim to the Medicare carrier who is the primary insurer. There is no other action you need to take.

 

Thereafter:

  1. The Medicare carrier adjudicates the claim and sends the processed claim and an explanation of payment (EOP) to you. A remark on your EOP from the Medicare carrier will advise you that they submitted the claim electronically to us.
  2. The Medicare carrier sends an electronic claim for secondary or supplemental payment consideration to us.
  3. We process the claim and send our own EOP and any additional payment to you.

This process, coordinated in partnership with the Centers for Medicare & Medicaid Services (CMS) via the national COBA program, allows claims for Medicare beneficiaries to be paid in an efficient and cost-effective manner.

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.

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

The ASC X12N 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.