Health Homes Billing – Claims Submission Guidelines (EmblemHealth)
Health Homes Billing is released using electronic formats. Pursuant to the Health Insurance Portability and Accountability Act (HIPAA), Public Law 104-191, institutional providers who submit claims electronically are required to use the HIPAA 837 Institutional (837i) transaction. This is the preferred method of claims transmission.
837 transactions will be validated as follows. It’s important to adhere to these guidelines:
- Billing Provider’s NPI.
- Billing Provider’s 9-digit Zip Code.
- The combination of NPI and Zip+4 are expected.
- Rate Code
- The Rate Code must be one previously approved for HH services.
- Some HH Rate Codes may not be payable by EmblemHealth and must be billed directly to eMedNY (example Rate Code 1861).
- The following Status Code(s) will be sent in the 277CA Response whenever the validation fails.
- Status Code 132 will indicate an issue with either the NPI or the 9-digit ZIP code.
- Status Code 116 will indicate the potential to submit to eMedNY.
- Status Code 726 will indicate the Value Information Amount (Rate Code) that needs to be corrected.
- Other parameters chosen to facilitate the validation of HH claims but not enforced currently:
- Taxonomy Code – This segment is expected in Loop 2000: PRV*BI*PXC*251B00000X~
- Facility Type Code – As per the Department of Health’s (DOH) guidance, only “34” is expected.
- Claim Filing Indicator Code (SBR09) can be any compliant value, but most providers will send “HM”.
- Date of Service (DoS) must be on or after the implementation date (July 1, 2018). However, claims submitted with DoS before this date will not be rejected by the 277CA front-end edit. Instead, they will be reported as DENIED in the 835-Electronic Remittance Advice with CARC 109: Claim/service not covered by this payer/ contractor. You must send the claim/service to the correct payer/contractor.
- Adjustments and Voids
- EmblemHealth will process Adjustments sent on the 837I. All 837 claims will be validated by interrogating the Claim Frequency Code (CLM05-3).
- New/Original claims are identified by a value of “1”.
- Adjustment claims are identified by a value of “7”.
- Whenever EmblemHealth receives CLM05-3 = 7 (or also “8” in the future), it is expected that the provider will also send EmblemHealth’s Claim Number in REF*F8 of Loop 2300 for the previously “paid” claim.
- EmblemHealth’s Claim Number is provided in CLP07 of the 835-Remittance Advice for all paid claims. The claim number must be valid/found; otherwise, the claim transaction will be rejected by the front-end 277CA with Status Code 35 (35 = Claim/Encounter not found).
- At this point, EmblemHealth is not able to process Void requests sent on the 837-claim format. Please continue to submit voids on paper until further notice.