Electronic Claims And Billing

Electronic Claims And Billing Process For Health Plan of San Joaquin Partners

Electronic Claims and billing are key components of quality health care is accurate, timely and efficient claims processing. Health Plan of San Joaquin (HPSJ) utilizes recognized industry standard billing codes and guidelines in the processing of Electronic Claims and billing. Partners can submit claims electronically and Health Plan of San Joaquin accepts the standard claim forms: Form 1500 (formerly CMS 1500), UB04, and CHDP PM160.

Before filing a claim, be sure to verify the member’s eligibility. HPSJ clearinghouse vendors for electronic claims submission are Emdeon and Office Ally. To submit claims electronically you will need to establish an account with Office Ally or Emdeon. Please contact one of these vendors to set up electronic claims submission

Submitting claims electronically has substantial benefits to you including:

  • Claim processing time is expedited – Electronic submission allows us to begin adjudicating your claims faster than if the claim is submitted by paper.
  • Cost effectiveness – Electronic submission eliminates the cost of purchasing billing forms, envelopes and postage.
  • Claims Submission Confirmation – Electronic submission allows you to receive an electronic confirmation of a claim submission from the clearinghouse.

Claims Adjudication Process

Claims are usually processed on a first in, first out basis. Each claim is subject to a comprehensive series of checks called “edits.” The edits validate all data information to determine if the claim should be paid, pended or denied. Claim edit checks verify many elements, including but not limited to:

  • Data validity
  • Prior authorization requirements
  • Patient eligibility on date of service
  • Provider contract status, participating (par) provider or non-participating (non-par) on date of service
  • Procedure/diagnosis code, and procedure/modifier compatibility
  • Other insurance coverage or benefits
  • Claim duplication.

A Clean Claim is a complete and accurate claim form that includes all provider and patient information, as well as patient records, additional information, or documents needed from the patient or provider to enable us to process the claim. The Clean Claim date is the date on which all such required information has been received.

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