HIPAA Claims Guide

EmblemHealth HIPAA Claims Guidelines All providers who are part of an EmblemHealth-contracted medical group – and individually credentialed providers who have a non-contracted provider as part of their group and share a TIN, NPI, or specialty/taxonomy code – are considered contracted providers for the purposes of claim payments and are considered “Substitute Practitioners.” Claims for Substitute Practitioner Read More →

Real-Time HIPAA Transactions

EmblemHealth Real-Time Eligibility Benefit Inquiry and Response (270-271) The ASC X12N 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 Read More →

HIPAA Claims Guide

EmblemHealth HIPAA Claims Guidelines In order for provider partners to be paid correctly and quickly, EmblemHealth provides guidance on best practices for claims submissions, payments, and finding information on claims submitted to EmblemHealth for processing. Participating Providers Claims must be received within 120 days post-date-of-service unless otherwise specified by the applicable participation agreement. Claims where Read More →

Electronic Claims Submission

Medicare PPO Electronic Claims Submission (EmblemHealth) The party (the clinician, provider group, facility, etc.) must submit an electronic claim to the Medicare carrier who is the primary insurer. There is no other action you need to take. The Medicare carrier adjudicates the claim and sends the processed claim and an explanation of payment (EOP) to you. Read More →

Coordination of Benefits

EmblemHealth HIPAA Guides: Electronic Coordination of Benefits Claims EmblemHealth accepts electronically submitted claims for payment as a secondary insurance carrier, except for commercial coordination of benefits claims. The HIPAA ASC X12N 837 transaction applies to services rendered by health care professionals, including 837P for medical practitioners, 837D for dental practitioners, and 837I for facilities and hospitals in Read More →

HIPAA claim training

  EmblemHealth Helpful Tips for Proper Setup of Electronic Billing Systems HIPAA promotes administrative simplification of claims payment using uniform EDI operations. This includes using standardized code sets, unique health identifiers, and measures to keep personal health information (PHI) secure. HIPAA compliance requires the use of these ANSI ASC X12N (Version 5010) EDI transaction standards. Find below some tips Read More →

Guide for Electronic Claims

EmblemHealth Guide for Electronic Claims Submissions Electronic data interchange (EDI) transactions provide an easier, faster way to submit and review claims. EmblemHealth supports Health Insurance Portability and Accountability Act (HIPAA)-compliant EDI transactions. We invite you to consider how electronic claims and other EDI transactions can benefit your practice or facility. Advantages of Electronic Claims Submission Less Read More →

Resolving EDI Errors

Tips for Resolving Errors with 270/271 Eligibility and Benefits Transactions UnitedHealthcare wants to help partners resolve errors to obtain member eligibility and benefits from their 270/271 Health Care Eligibility and Benefit Inquiry and Response transactions. Its current search logic allows you to enter different criteria related to the member or patient for the eligibility and benefits inquiry transaction Read More →

EDI 278N

EDI 278N: Hospital Admission Notification: United Healthcare Guidelines Using Electronic Data Interchange (EDI) for all eligible UnitedHealthcare transactions can help your organization improve efficiency, reduce costs and increase cash flow. UnitedHealthcare encourages you to use the following tools and resources to help you get started with electronic transactions. Use the Hospital Admission Notification (278N) transaction to exchange Read More →

EDI training

EDI 278I: Prior Authorization and Notification Inquiry (United Healthcare) Use the Prior Authorization and Notification Inquiry (278I) transaction to check the status of previously submitted authorizations and notifications. Electronic authorization and notification inquiries can be submitted in real-time or batch mode, and you will receive a unique inquiry ID for confirmation of submission. Benefits Streamline administrative tasks Read More →