EmblemHealth Electronic Claims Submission Requirements
EmblemHealth Electronic Claims should not be duplicated. When duplicate claims are submitted, vendor potentially delays claims processing and create confusion for the member. Attachments cannot be submitted electronically at this time. However, most claims should be submitted electronically. If supporting documentation is required for the settlement of a vendor claim, EmblemHealth 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(CPT)/Healthcare Common Procedure Coding System (HCPCS) reporting guidelines, please use theto submit claims for unpublished procedure or service codes. This information will be used to determine appropriate payment and claim adjudication in conjunction with the member’s benefit plan.
Electronic Coordination of Benefits Claims
EmblemHealth PPO and HMO 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.
Real Time Eligibility Benefit Inquiry and Response (270-271)
The ASCX12N 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.