EmblemHealth Electronic Claims

EmblemHealth Electronic Claims (EDI Transactions) Requirements

EmblemHealth Electronic Claims help practitioners manage their practices more effectively. EmblemHealth supports HIPAA-compliant electronic data interchange transactions. Electronic claims submission provides an easier, faster way to submit claims. Some of the advantages of electronic claim submission includes:

  • Quicker claims submission, which means faster reimbursement to you.
  • No paper claims to stock and complete.
  • Simplified record keeping by eliminating lost claims paperwork.
  • Reduced clerical time and the costs to process and mail paper claims.
  • Electronic Remittance Advice (HIPAA 835 transaction) – EmblemHealth can provide paper remittances.

The pathways for electronic claims submission to EmblemHealth:

  • Practice management system vendors, billing services, and practitioners that submit claims and other EDI transactions via one of EmblemHealth’s contracted claims clearinghouses.
  • Practice management system vendors and billing services that submit claims and other EDI transactions directly to EmblemHealth.

Important EDI requirements:

  1. National Provider Identifier (NPI) – Ensure your software is capturing and correctly populating your NPI in your electronic claims. Otherwise, your claims will be rejected (not accepted) by EmblemHealth. If a CMA has an NPI, according to the NYS Department of Health, the NPI will be used to identify the CMA. Supplemental guidance will be issued to accompany the taxonomy grid.
  2. Payer ID Number – Ensure that your claims are routed correctly via your vendor and/or claims clearinghouse. Please refer to the sample 837I file.
  3. Date(s) of Service (DOS) – Ensure the appropriate data items are populated correctly or your claims will be rejected (not accepted) by EmblemHealth.
  4. ICD-10/CPT4 Codes – Helps to ensure the correct settlement of your claims.
  5. Membership Information – Helps to ensure EmblemHealth accepts your claims for covered members.
  6. Ensure all transactions transmitted to EmblemHealth each month meet all requirements for acceptance through EmblemHealth’s electronic gateway. However, a paper claim is required for processing voids or adjustments.

Avoid Duplicate Claims Submissions by Using Your 277CA Report (Claims Rejection Report). If you submit duplicate claims, you may actually delay claims processing and can potentially create confusion for the member.

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