24-943m How to Make Sure Your Claims Aren't Rejected
Date: 09/16/24
Follow these tips to ensure your paper or Electronic Data Interchange (EDI) claim submission isn’t rejected
Submitting EDI claims
Transitioning to EDI for claim submissions can significantly improve the efficiency and accuracy of your billing processes. EDI offers several benefits:
- Enhanced efficiency:
- EDI facilitates the electronic submission of claims, reducing the time spent on manual entry and paper handling, providing access to tools for tracking claims status, timely filing, and receiving daily accept/reject reports.
- Manual entries are prone to quality errors and are attributed to higher costs with longer processing times.
- Misdirected claims can be routed electronically, alleviating the need to send paper claims.
- Improved compliance and security:
- EDI technology is designed to comply with the Health Insurance Portability and Accountability Act (HIPAA), ensuring secure and confidential handling of patient information.
- Streamlined workflow:
- Providers can receive electronic remittance advice (ERA), which simplifies account reconciliation by detailing multiple claims and allowing automatic posting to accounts receivable systems.
- Convenient payment options:
- Electronic funds transfer (EFT) automates the deposit of payments into providers' accounts, offering a secure and efficient alternative to paper checks.
Submit claims through Availity and Ability
Successful EDI claim submission requires the use of electronic reporting made available through your vendor and/or clearinghouse. Wellcare By Health Net (Health Net) returns claims acknowledgements to the clearinghouse with notifications of acceptance or rejection of individual claims. You can review these reports to check the status of their submission.
Refer to the table below for contact information and payer identification numbers for these clearinghouses.
Clearinghouse | Contact information | Payer ID |
Ability (MD Online) | 95567 | |
Availity | 68069 |
If you need assistance in setting up or determining capability to submit electronic claims, please email or call
800-225-2573, ext. 6075525. You may also reach out to your assigned provider reimbursement and contracting specialist for more information.
Visit Electronic Data Interchange for more details about EDI and how it can help you and your practice.
Submitting paper claims
Submitting claims via EDI or web-based platforms is preferred over paper submissions due to increased efficiency and lower risk of errors. However, if you must submit paper claims, adhere to the following guidelines to minimize the chance of rejection:
- Use the right fonts: When filling out claim forms, type or print everything in either 10- or 12-point Times New Roman font. This makes it easy for the computer to understand the information.
- Keep it simple: Don't use highlights, italics, bold text, ink stamps, or staples for forms with multiple pages. Just make sure everything is neatly typed.
- Get the right forms: If you're a physician or a supplier, use the CMS 1500 (02/12) claim form. If you're from a hospital, use the CMS 1450 (UB-04) claim form. Please note that we do not provide these forms. Providers and facilities are responsible for purchasing their own claim forms.
- Use the right colors: Forms should be in the original red and white (Flint OCR Red, J6983, (or an exact match)) version to be accepted. Black and white forms, handwritten forms, or non-standard forms will be rejected. Forms can be obtained from printers or printed in-house, as long as they follow the specifications developed by the National Uniform Claim Committee.
- No photocopies: Photocopies of claim forms are NOT acceptable. Only use the Flint OCR Red, J6983, (or an exact match) ink for printing claim forms. Don't use photocopies because the computer might not read them properly. Downloaded copies won't work either because they might not look exactly like the original.
Additional information
Additional information about the professional paper claim form (CMS-1500).
Information about the UB04 form can be found at Institutional paper claim form (CMS-1450).
If you have questions regarding the information contained in this update, contact Provider Services by using the information below or provider portal.
Line of business | Phone number | |
Ambetter from Health Net IFP Ambetter PPO | ||
Ambetter HMO | ||
Health Net Employer Group HMO, POS, & PPO | ||
Medicare (Individual & Employer Group) (Wellcare By Health Net) | ||
Medi-Cal (including CS and ECM providers) | N/A |
This information applies to Participating Physician Groups (PPGs).
For Medi-Cal, this information applies to Amador, Calaveras, Inyo, Los Angeles, Molina, Mono, Sacramento, San Joaquin, Stanislaus, Tulare and Tuolumne counties.