ELECTRONIC CLAIMS

The Health Plan accepts both professional and institutional electronic claims through its clearinghouse Emdeon. The HP uses Electronic Data Interchange (EDI) for electronic claims submission. EDI eliminates the need for your office staff to prepare claims manually or re-key repetitive transaction information. There are no paper forms, envelopes, or stamps.

Submitting a Claim

Claims can be sent directly to Emdeon. To do this, you must be a customer. To enroll in Emdeon call 1-800-845-6592. Claims can also be sent by your clearinghouse. To do this, your clearinghouse must have a forwarding agreement with Emedon. This arrangement allows your clearinghouse to pass the claims on to Emedon so that the HP can receive them. You will need to contact your Clearinghouse to see if this arrangement exists.

Claim Submission Guidelines

Special attention should be paid to the following fields:

A. Payer Identification number: 38343

B. Billing Provider: 85

C. Individual Provider: Enter each part of name in separate fields using the format shown below. Do not use any punctuation. LASTNAME FIRSTNAME MIDDLEINITIAL (not required) - Example: NM1*85*1*SMITH*JOHN*A**

D. Group Practices/Companies: Enter as much of the full name as possible in last name field using the format shown below. Do not use any punctuation. GROUPNAME — Example: NM1*85*2*SMITH RADIOLOGY GR**

E. Billing Provider Address:
1. Street: Use standard US Post Office street abbreviations (ex. N, E,S, SW, NE) in the format shown below. Do not use any punctuation. 999 S Healthcare ST or PO BOX 123
2. City, State, and ZIP: Use full city name and standard Post Office two-digit state abbreviations. Use the five digit zip code.

F. Member Group Number (Loop: 2000B, Segment: SBR03): This is a required field but can be defaulted to 999999 if number unknown.

G. Member Identification Number (Loop: 2000B, Segment: SBR03): A required field. All identification numbers must contain HPMS plus 6 or 7 numerical digits shown in the format below. An incorrect identification number will cause the claim to be rejected. The identification number must mirror the number on the member’s CHP card. This is not the member’s Medicaid, Social number. Example: HPMS-123456 or HPMS7-123456

H. Member Name: A required field. Enter each part of the name into a separate field using the format shown below. Incorrect spelling of a member’s name will cause the claim to be rejected. The spelling must mirror the spelling on the member’s HP card. Example: LASTNAME FIRSTNAME MIDDLEINITIAL

I. Members Address:
1. Street: Use standard US Post Office street abbreviations (ex. N, E, S, SW, NE) in the format shown below. Do not use any punctuation. Example: 999 S Healthcare ST or PO BOX 123
2. City, State, and ZIP: Use full city name and standard Post Office two-digit state abbreviations. Use the five digit zip code.

J. Member’s Date of Birth and all other Date Fields: Enter each part of the date in the format shown below. Do not use any punctuation. An incorrect date of birth will cause the claim to be rejected. CCYYMMDD

K. Claim Detail: Units (Professional claims: Loop: 2400, Segment: SV104, Institutional claims: Loop: 2400, Segment: SV205) Value can not be zero. Do not use preceding zeros in front of the value

Questions

If you need the status of a claim that you have submitted or have questions concerning rejections received from the HP please contact us at 1-866-291-8691. Providers should note that positive submission status received from the clearinghouse does not guarantee claim were received by the HP. Clearinghouse file structure edits may differ from health plan claim requirements.