EDI Transactions

01/02/2020

Date Issued: 5/22/2015

Electronic data interchange (EDI) transactions help practitioners manage their practices more effectively. EmblemHealth supports HIPAA compliant electronic data interchange (EDI) transactions. In particular, electronic claim submission provides an easier, faster way to submit claims. Today, tens of thousands of health care practitioners have eliminated paper claims and are submitting electronic claims to EmblemHealth in HIPAA compliant professional provider (837P), institutional provider (837I) and dental provider (837D) EDI claims transaction formats. We invite you to consider how electronic claims and other EDI transactions can benefit your practice.

Some of the advantages of electronic claim submission

  • Quicker claim 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.

The pathways for electronic claim submission to EmblemHealth

Providers, both institutional and professional, may use practice management system vendors, billing services or clearinghouses to submit claims and other EDI transactions to EmblemHealth.

Please Note: Practice management system vendors, billing services and clearinghouses offer a variety of EDI solutions to the health care community and charge fees or transaction costs for their services. EmblemHealth does not specifically recommend or endorse any vendor or billing service.

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, copays, etc. 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.

How to Submit Electronic Claims

The Health Insurance Portability and Accountability Act (HIPAA) promotes administrative simplification of claims payment through the use of uniform electronic data interchange (EDI) operations. This includes using standardized code sets, unique health identifiers and measures to keep personal health information secure. HIPAA compliance requires the use of these ANSI ASC X12N (Version 5010) EDI transaction standards.

EmblemHealth and Cognizant Healthcare Services, LLC (a subsidiary of Cognizant Technology Solutions) have partnered. Part of that business venture includes encouraging our trading partners to submit electronic claims through Cognizant’s TriZetto Provider Solutions (TPS). TPS — a Cognizant Company — is more than just a clearinghouse. They provide exceptional service by combining enhanced trading partner solutions with superior client support. EmblemHealth’s preferred electronic data interchange (EDI) connection is TPS. If you would like to connect directly to TPS for free, please complete this form. If you already use a clearinghouse, such as Ability, SSI, Availity, or Claim Logic, your claims will be sent to EmblemHealth. There will be no changes and you do not need to complete the form.

For more information, please email ttpssupport@trizetto.com.

Important Requirements

National Provider Identifier (NPI)

Please contact your practice management system vendor to ensure your software is capturing and correctly populating your NPI in your electronic claims. Otherwise, your claims will be rejected by EmblemHealth.

Revised NPI Requirements for Professional Provider Claims (837P)

  • Billing Provider 2010AA: An NPI is required for health care providers in the United States or its territories.
  • Pay-To Address 2010AB: There is no NPI in the Pay-To Address loop. The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address.
  • Rendering Provider 2310B: Only required when the Rendering Provider information is different from the information carried in Billing Provider Loop 2010AA. If this loop is sent, an NPI is required.
  • Rendering Provider 2420A: Only required when the Rendering Provider information is different from the information carried in the 2310B or 2010AA loops. If this loop is sent, an NPI is required.

Revised NPI Requirements for Institutional Claims (837I)

  • Billing Provider 2010AA: An NPI is required for health care providers in the United States or its territories.
  • Pay-To Address 2010AB: There is no NPI in the Pay-To Address loop. The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address.

Revised NPI Requirements for Dental Provider Claims (837D)

  • Billing Provider 2010AA: An NPI is required for health care providers in the United States or its territories.
  • Pay-To Address 2010AB: There is no NPI in the Pay-To Address loop. The purpose of Loop ID-2010AB has changed from previous versions. Loop ID-2010AB only contains address information when different from the Billing Provider Address.
  • Rendering Provider 2310B: Only required when the Rendering Provider information is different from the information carried in Billing Provider Loop 2010AA. If this loop is sent, an NPI is required.

Payer ID Numbers

GHI PPO: 13551 
GHI HMO: 25531 
HIP: 55247 
Vytra: 22264 
ConnectiCare VIP Medicare Advantage: 78375

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.

HIPAA Transaction Companion Guides

We have made available transaction-specific companion guides to the ASC X12N Implementation Guides adopted under HIPAA. They contain specifications for electronic transmission to EmblemHealth. The guides can assist your vendor or clearinghouse in the set-up and testing process, as well as complying with EmblemHealth-specific transaction requirements that guarantee smooth and successful EDI transaction responses.

The ASC X12N 270/271 (005010X279A1) Health Care Eligibility Benefit Inquiry and Response Companion Guide and the ASC X12 276/277 (005010X212E2) Health Care Claim Status Request and Response Companion Guide are also available in Claims Corner.

Avoiding Duplicate Claims Submissions

When duplicate claims are submitted, you may actually delay claims processing and can potentially create confusion for the member. You may access duplicate claims submissions at Claims Corner for more information.

Electronic Claim Attachments

Attachments cannot be submitted electronically at this time. However, most claims should be submitted electronically. If supporting documentation is required for the settlement of your claim, we will request the additional information.

Please note: We will be enhancing our technology to support an electronic attachment capability for professional practitioners. We will notify you when we are ready to accept attachments electronically.

Electronic Coordination of Benefits (COB) Claims

EmblemHealth accepts electronically submitted claims for payment as a secondary insurance carrier. 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 which payment responsibility is apportioned between the primary insurance carrier and a second carrier.

Our ability to accept Coordination of Benefit (COB) claims electronically improves the overall processing of claims payments. Electronic COB claims will:

  • Allow for prompt review and payment
  • Ensure fewer claims are denied for missing COB information
  • Reduce human error
  • Be available to HMO and PPO providers at all levels of technological readiness

Accepting electronic COB submissions is another means to improve the efficacy of our claims adjudication. Correct submission of electronic claims to EmblemHealth will also ensure we can process your claims more quickly and accurately. Commercial COB electronic claims that do not meet the requirements set forth in the 5010 Implementation Guides or are submitted without the necessary information about the other payer may be rejected for missing, incomplete or invalid information.

GHI PPO, GHI HMO, HIP and VYTRA 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.

EDI Help Desk

All inquiries and comments regarding initiation, set-up, submission and support should be directed to our EDI Help Desk at 1-212-615-4362, Monday through Monday through Friday, 9 am to 5 pm (ET).

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