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Claims Submission for EmblemHealth Patients

Before submitting a claim, you need to determine if your patient is an HCP DIRECT member or an EmblemHealth Cohort 2 member.

  • An HCP DIRECT member is a patient assigned to a PCP who is directly contracted with HCP

  • An EmblemHealth Cohort 2 member is a patient is assigned to a PCP who is directly contracted with EmblemHealth

Always validate patient eligibility to determine which claims submission process to follow.

Electronic (EDI) Claims

HCP’s preferred method of claims submission is electronic through Change Healthcare. This process streamlines your claims, improves response time and enhances correction capabilities. In addition, it provides you with a record of your claim upload.

Setting up an account with Change Healthcare

  • In order to submit claims via EDI through Change Healthcare to HCP, you must first establish an account.
  • To establish an account, contact Change Healthcare at 1-855-304-5269 or visit www.changehealthcare.com

To submit HCP Direct Claims:

HCP’s Payer ID number with
Change Healthcare is 11328

 

To submit EmblemHealth Cohort 2 Claims:

EmblemHealth’s Payer ID number with
Change Healthcare is 55247

 

Helpful Tips for Successful EDI Transmission

  •  Submit EDI claims with the Provider’s full and proper name and National Provider Identifier (NPI) number.
  • Verify that the Member’s first and last names, health plan ID and date of birth match current eligibility records. Mismatched patient information may result in the rejection of your claim.
  • Retain copies of your EDI transmission acceptance reports as evidence of transmission.

Paper Claims

All paper claims for HCP Direct members must be submitted on a properly completed CMS 1500 or UB04 claim form. All HCP Direct paper claims should be mailed to:

HealthCare Partners, MSO
Attn: Claims
501 Franklin Avenue, Suite 300
Garden City, NY 11530

All paper claims for EmblemHealth Cohort 2 HCP members must be submitted on a properly completed CMS 1500 or UB04 claim form. All EmblemHealth Cohort 2 paper claims should be mailed to:

EmblemHealth
PO Box 2845
New York, New York 10116

 

Helpful Tips for Successful Paper Claim Submission

  • Be sure to properly complete your claim form. Any missing or omitted information may lead to a delay in processing or rejection of your claim.
  • Always include your Tax ID Number and NPI (National Provider Identification) number.
  • The Centers for Medicare and Medicaid Services (CMS) requires that ICD-10 codes be submitted at the highest level of specificity. Failure to submit the most specific ICD-10 code(s) may result in rejection of your claim.
  • Do not use colored highlighters on your claim forms. All paper documents are scanned using light sensitive equipment. Highlighted areas can become fully obscured during the scanning process.

Timely Filing

The timely filing for Medicaid, Medicare and Commercial claims is within 120 days of the date of service. Where HCP is the secondary payor under Coordination of Benefits, the time period shall commence once the primary payor has paid or denied the claim.

Check Claim Status with EZ-Net

Use EZ-Net, HCPs secure web based data exchange application, to view the status of an existing claim previously submitted to HCP.

Login credentials for EZ-Net are required. Learn More

Claim Reconsideration

As a participating HCP provider, you may request Claim Reconsideration for any claim submission that you feel was not properly processed. Please download the Claims Reconsideration Request Form and follow the instructions. Completed forms can be faxed to (516) 394-5693 or mailed to:

HealthCare Partners, MSO
Attn: Claims Reconsiderations
501 Franklin Avenue, Suite 300
Garden City, NY 11530

 

Physical and Occupational Therapy Claims

Physical and Occupational Therapy claims for all Emblem members, both HCP DIRECT and EmblemHealth Cohort 2 patients, are handled by Palladian. Visit https://www.evicore.com/provider

Behavioral Health Services Claims

HCP DIRECT and EmblemHealth Cohort 2 members Behavioral Health Services are managed by Beacon Health Options. For information on prior approval, claims submission and claims status please visit Beacon Health Options.