Providers
Claim Submissions

The Initial Claims Unit is responsible for processing Professional and Institutional claims for all line of business. Providers can either submit electronic or paper submissions. Below is important information on submissions and billing reminders.

If you do not currently use electronic claims processing and are interested in learning more about it, please visit our Electronic Data Interchange page.

Electronic Claim Submissions

The following payer IDs are required on claims sent electronically for our health plan members:

  • Health Partners Plans Medicaid / CHIP / Jefferson Health Plans Medicare Advantage HMO / Jefferson Health Plans Individual and Family: Payer ID# 80142
  • Jefferson Health Plans Medicare PPO: Payer ID #RP099
  • Jefferson Health Plans New Jersey Medicare PPO: Payer ID #NJ099

For questions, contact EDI@jeffersonhealthplans.com.

Paper Claim Submissions

When submitting paper claims, please be sure to use the correct P.O. box for processing.

Refer to the Important Addresses page for a complete listing of plans and corresponding addresses.

Claim Billing Reminders
  • Refer to the CMS and DHS requirements when billing.
  • Initial claim submissions must be submitted 180 calendar days from the date of service or discharge date to submit.
  • Claims must be filled in properly or they will be rejected and returned for re-submission with the proper information.
  • A valid member ID is required for the line of business at the time of service.
  • Submitting claims on the CMS-1500 and CMS-1450 (also referred to as the UB-04):
    • The CMS-1500 form is a claim form submitted by non-institutional claims for health care services provided by physicians, other providers, and suppliers.
    • The CMS-1450 (also referred to as UB-04) is a claim form billed by institutional facilities such as hospitals or outpatient facilities.
  • Include the National Provider Identifier (NPI) which is assigned to the provider by the Centers of Medicare and Medicaid Services (CMS). It is a valid 10-digit numeric value based on rules supplied by CMS. Failure to include the NPI will result in rejection of the claim.
    • CMS-1500: All claims MUST have your Individual NPI number and group location NPI in the appropriate fields.
      • Your Individual number must be entered in box number 24J of the CMS-1500 form. If you are a non-physician practitioner and do not have a medical license number, please use your social security number in box 19. If you are an ancillary provider, please provide your group NPI# in box 24J.
      • Your group location NPI# number must be entered in box number 33A.
    • UB-04: All facility claims MUST have your Health Partners Plans or Jefferson Health Plans ID number and the facility’s NPI number in the appropriate fields.
  • Paper claims include all documentation to support the processing of the claim, for example, primary EOP or denial letters. Electronic claims can be submitted with other insurance information.
Medicaid Home Health Providers
  • Obtain an authorization for the service.
  • Record EVV hours and minutes in HHAeXchange with the correct modifiers if applicable.
  • Create and submit a claim using HHAeXchange. If provider has opted to use another platform for billing, the provider is responsible for sending claim data to HHAeXchange and Sandata so the MCO is prepared for encounter filing.
  • Submit appropriate provider type and specialties-based DHS EVV requirements. Check with DHS to confirm the appropriate provider type and specialty for submissions.
  • Document other insurance information in the HHAeXchange Secondary Screen, inclusive of non-covered information from the primary insurance.
  • For Claims Reconsideration appeals, submit documentation to support the appeal (i.e. EOP, Denial and Exhaustion Letters) in the Provider Portal.
Claim Resubmissions
  • Professional claims must indicate corrected claim, and the original claim number must be provided.
  • For institutional claims, please use the frequency code 7.
  • Claims must be submitted within 180 days of the EOP paid date of the original submission.
  • When a member has other insurance, please submit the primary other insurance documentation within 60 days of the primary carrier payment date (i.e. EOP or Denial Letter).