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Claims Submission for EmblemHealth Patients

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.

Create 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 (855) 304-5269.

To Submit HCP Direct Claims:

HCP’s Payer ID number with Change Healthcare is 11328.

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 must be faxed to (516) 515-8870 or mailed to:

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

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 the 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 about EZ-Net.

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.

Out-of-Network Providers Submitting Medicare Advantage Claims

For claims denials that resulted in partial or zero payment: You are only permitted to file a standard appeal for a denied Medicare Advantage claim if you complete a Waiver of Liability, which states that you will not bill the member regardless of the outcome of the appeal.

You must file the appeal within 60 calendar days from the date of this explanation of payment.

Physical and Occupational Therapy Claims

Physical and Occupational Therapy claims for all HCP DIRECT EmblemHealth members are handled by Palladian Physical and Occupational Therapy.

EDI via Change Healthcare
Use Payer ID: 37268

Mail paper claims to:

Palladian Muscular Skeletal Health
PO Box 366
Lancaster, NY 14086

Behavioral Health Services Claims

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

EDI: Contact Beacon Health Options

Mail paper claims to:

EmblemHealth Behavioral Health Claim Services
P.O. Box 1850
Hicksville, NY 11802-1850