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Eligibility and Claims


What information do I need to submit my claims electronically to Jefferson Health Plans?

The following items are required on claims sent electronically for Jefferson Health Plans members:

    • ELECTRONIC PAYOR ID for Medicare PPO: RP099
    • ELECTRONIC PAYOR ID for ALL other products (Medicaid, CHIP, Medicare HMO/DSNP, Individual and Family.-  80142

National Provider Identifier (NPI) Failure to include this information will result in rejection of the claim.

Please refer to the Health Partners Plans 837I&P Companion Guide for the provider number field and other information required for electronic claim submissions. 

What is my NPI ID Number?

The National Provider Identifier 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.

What do I do if I do not have a computer to submit claims electronically?

If you do not have the appropriate equipment for electronic claims process, we suggest that you contact Smart Data Solutions (SDS), or your billing software vendor, for more information.  

I do not currently submit claims electronically. How do I begin?

Contact SDS directly. All trading agreements would come through them exclusively. You can contact them directly in order to set up a trading platform.

What if my billing software vendor uses another clearinghouse such as NDC, Med-E America, ETS, Equifax, etc.?

Please contact your billing software/clearinghouse vendor for details.

Once I am set up to send claims electronically, how many claims should I initially send?

We recommend that you start by sending 20-30 claims to ensure no issues exist. We also suggest that you contact the Claims Department (EDI) Support Line after submitting the first batch of claims so that we can analyze them for any potential issues.

Why can’t I just use email to submit my claims electronically?

Email is very different than EDI. The EDI data is transmitted in a structured format, based on the use of transaction standards, which ensures that all participants use a common language.

Are  reports created for providers that identify claim rejections/errors?

Yes, there are two types of reports available to providers.  

  • RPT01/RPT05: This report identifies all claim rejections with invalid and/or missing data that have been sent back to the provider from SDS. Claims rejected at this level cannot be identified by Jefferson Health Plans and are rejected before reaching our claims processing system. To inquire about claim error(s) found on this report, please contact your billing software vendor.
  • RPT10/RPT11: This report identifies all claim rejections with invalid and/or missing data that have been sent back to the provider from Jefferson Health Plans. To inquire about claims errors found on this report, please contact the Claims Department (EDI) Support Line and provide the Carrier Reference Number (Car Ref #) of the error(s) in question to the representative.

Please note: The provider is responsible for updating all errors found on these reports and for retransmitting the corrected data to Jefferson Health Plans in a timely manner.

For more information

  • Jefferson Health Plans Provider Services Helpline: 1-888-991-9023