Electronic Claims

Electronic Claims Notes: Coordination of Benefits, Clean Claim, Claims Reimbursement

Electronic Claims Notes given in the blog refer to Coordination of Benefits, Clean Claim, Claims Reimbursement guidelines for Health Plan of San Joaquin payers.

Coordination of Benefits (COB)

When HPSJ or the employer-sponsored plan of an SJHA client is the secondary payer, all claims must be submitted within 365 days from the date of payment on the primary payer’s Explanation of Benefits (EOB) form. A copy of the EOB must be attached to the claim if submitted via paper. COB data can also be submitted electronically if your claim is filed electronically. Medicare Part A and B patient claims must be submitted with the Explanation of Medicare Benefits (EOMB) form attached to the claim. If the patient’s primary plan denies services and requests additional information, the information must be submitted to the primary insurance carrier prior to submitting to HPSJ or SJHA.

Clean Claim

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. Providers are required to submit all claims regardless of date of service on the version 02/12 HCFA 1500 claim form. Any claims received on the version 08/05 HCFA 1500 claim form after April 1, 2014 will be returned to you.

Claims Reimbursement

Claims for participating providers will be reimbursed according to the terms specified in your Provider Agreement. Claims for non-participating providers will be adjudicated primarily in accordance with Medi-Cal guidelines for Medi-Cal patients and according to other established guidelines determined by the plan for nonMedi-Cal patients. Providers will receive a Remittance Advice, (RA) indicating payment or the denied reason if the claim is denied.

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