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:

  • Jefferson Health Plans EverWell / Jefferson Health Plans 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 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.
Common Reasons for Claim Rejections or Denials

Do not use the Medicaid ACCESS card number when submitting claims for MA members. Use of this number will cause a claim rejection. Until DHS has assigned a permanent Medical Assistance number, newborn claims will be denied.

For electronic and paper claims, a provider must use both the individual and the billing NPI number. If these numbers have not been established in our processing system, it may cause a provider to appear as non-participating, thus requiring authorization for services. Without an authorization or a valid legacy provider number, all claims will be denied.

Providers are responsible for communicating all service dates, beginning/admission through ending/discharge. If the scheduled service date is canceled or rescheduled, providers must call Inpatient Services or Outpatient Services to update the authorization to reflect the change. Any service dates not included in the authorization will be denied.

Claims must be coded with the most current procedure and diagnosis codes at the highest level of specificity. Unless claims are properly and completely coded, they will be rejected if invalid or denied if obsolete.

Unlisted and miscellaneous codes do not provide the description of a specific procedure or service. We require that the service reported by the unlisted procedure code be identified when clinical information is provided.

For any unlisted procedure codes, attach the following supporting documentation:

  • A concise cover letter outlining the procedure or service being reported with the unlisted procedure code.
  • An operative report or office notes describing the services performed and supporting the medical necessity of the procedure.
  • An appropriate comparable procedure and the differences between it and the new procedure performed. Include these differences in the cover letter.

Providers should consider what type of information would best help us understand exactly what is being billed. If we have any further questions about the service or item, additional information may be requested.

Examples of unlisted procedure codes include:

  • 21299 Unlisted craniofacial and maxillofacial procedure
  • 37799 Unlisted procedure, vascular surgery

Be sure to report the appropriate unlisted code for the category or type of procedure performed. For example, report an unlisted laparoscopy procedure of the esophagus with 43289 Unlisted laparoscopy procedure, esophagus, not 43499 Unlisted procedure, esophagus.

Except for emergency services and allotted out-of-network benefits for Jefferson Health Plans Medicare and Individual and Family Plans PPO products, all non-participating providers require prior authorization. Without proper authorization, non-participating provider claims will be denied.

Providers must verify coverage every time a member is seen for services. We can be contacted to review other insurance information on file. If we are billed before the primary carrier has made a determination, the claim will be denied.

We will only pay up to our allowable fee schedule or contracted rate, minus what the primary payer did or would have paid, for example deductibles, copayments or coinsurance, as demonstrated on the EOP attachment. The claim will be denied until the required EOP information is submitted. The primary EOP must be submitted to us within 60 days of being issued.

Certain benefit packages have limitations on the number of services allowed. We will only pay for services covered under the applicable benefit package and will only reimburse the allowable portion of the claim, such as coinsurance and deductible.

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).