Change Healthcare—one of the Benefit Funds’ vendors and a prominent healthcare technology provider linking providers, payers and patients—experienced a cyberattack on Wednesday, February 21. Although the cyberattack did not target the Benefit Funds’ systems, we immediately severed network connections with Change Healthcare to prevent potential risks to our members’ data. As a result, we cannot exchange electronic transactions (including claims submissions, ERAs and EFTs) through Change Healthcare’s platform. We do not know how long Change Healthcare will be unavailable. In the meantime, you may:
- Submit electronic claims via Inovalon Provider (FKA Ability) by calling (800) 548-2890.
- Complete and submit an intake form, and an Inovalon Provider representative will contact you.
Notice to 1199SEIU Providers and Hospitals: Coverage of Telehealth Services Made Permanent
We will continue to cover telehealth services for your 1199SEIU patients. This includes visits via phone, video and other virtual means for all eligible medical and mental health services, including COVID-19 related services. Please note: Effective October 15, 2021, the Benefit Funds no longer covers telehealth services provided by an urgent care center and will deny any claims with telehealth procedure codes or modifiers where the place of service is 20.
During the Public Health Emergency, the Benefit Funds covered all codes with a telehealth modifier of 95 or GT, or place of service code 02. Effective 05/12/2023, coverage determination will be made based on the Benefit Funds’ telehealth policy.
Electronic Claims
We accept all claim submissions electronically through Change Healthcare.
Our payor number is 13162; CPIDs 4551 (INST) and 5405 (PROF)
You must register with Change Healthcare to receive Electronic Remittance Advise (ERA).
Contact Change Healthcare for Support
For Registration/Payer Enrollment
(800) 527-8133 (option 1)
(916) 267-2963 (e-fax)
For Claims, Remits and Claim Status
(800) 527-8133 (option 2)
(916) 267-2968 (e-fax)
Paper Claims
- Send UB04 claims to: PO Box 933, New York, NY 10108-0933
- Send CMS 1500 claims to: PO Box 1007, New York, NY 10108-1007
- For ADA claims:
- The Benefit Funds do not administer dental benefits for 1199SEIU members. Please review your 1199SEIU patient’s dental identification card to identify the carrier and locate associated contact information for that carrier.
Electronic Payments
The 1199SEIU Benefit Funds have selected Change Healthcare (formerly known as Emdeon and Capario) as their electronic payment and remittance reporting provider. There is no cost to you to use Change Healthcare ePayment and enrollment is free.
Get Paid Faster with EFT payments
With Change Healthcare ePayment, you can accelerate your reimbursement cycle since you don’t have to wait for checks to arrive in the mail. In addition, it eliminates manual processes such as sorting and opening mail and reconciling paper-based claim payments.
Simplify Reconciliation
Once enrolled in ePayment, you will continue to receive paper Explanation of Payment (EOP) statements for up to 45 days, after which the Benefit Funds will generate a downloadable HIPAA-formatted 835 ERA file through your respective clearinghouse. You can also use Change Healthcare Payment Manager, an online application available for Change Healthcare ePayment users, to view and print EOP images.
Enroll in Change Healthcare/Emdeon
Telephone: (866) 506-2830 (select option 1)
Claim Editing Rules
About ClaimsXten: On March 1, 2021, the 1199SEIU Benefit Funds upgraded the comprehensive claims auditing software to ClaimsXten version 2.2.2. ClaimsXten utilizes the National Correct Coding Initiative (NCCI), which includes the Procedure-to-Procedure (PTP) and Outpatient Code Editor (OCE) edits, as well as Medically Unlikely Edits (MUEs). The NCCI was developed by the Centers for Medicare & Medicaid Services (CMS) to promote correct coding methodologies and limit improper coding and other inappropriate reimbursements. All code and NCCI data is updated quarterly, at a minimum. For additional information on NCCI, please visit the CMS website here.
ClaimsXten: Information and FAQ
ClaimsXten Select MUE Practitioner Rule Education
To ensure that professional claims billed on the CMS 1500 form are paid accurately and according to standard Medicare claims rules, starting on October 1, 2022, the 1199SEIU Benefit Funds began applying the Medicare Medically Unlikely Edits (MUEs) for Practitioners in the ClaimsXten Select audit application. The Benefit Funds are now adding the standard Medicare claims coding rule to audit professional claims for the clinically determined standard practitioner MUEs for a date of service (DOS).
As you know, ClaimsXten Select’s Medicare MUE Practitioner DOS (MCARE_MUE_PRACTITIONER) rule for professional claims identifies claim lines where the number of CPT/HCPCS units billed exceeds the clinically defined maximum when reported by the same provider for the same member on the same DOS. The rule takes the MUE adjudication indicator (MAI) into account. The MAI indicators are as follows:
- MAI 1 = claim line edits
- MAI 2 = DOS edits (based on policy)
- MAI 3 = DOS edits (based on clinical benchmarks)
Data source: ClaimsXten Select directly uploads CMS MUE values from Medicare’s National Correct Coding Initiative Edits.
Typically, services that are not covered, separately payable or reasonable, and are bundled, necessary or statutorily excluded, are assigned an MUE value of zero (0) by CMS. Some drug codes may also be assigned an MUE value of zero.
For codes with a CMS MUE value of zero:
- The following code rules have a default frequency value based on anatomic considerations, CPT/HCPCS code descriptors, CPT instructions, CMS policies/MUE values, the nature of the service/procedure, the nature of analyte, the nature of equipment and clinical judgment:
- American Medical Association (AMA)
- Centers for Medicare & Medicaid Services (CMS)
- McKesson Clinical Review (McKesson)
- Codes with no default frequency value, such as those in the Base Code Quantity rule, will be excluded from unit
auditing.
For additional information on MUE, please visit the CMS website: www.CMS.gov/Medicare/Coding/NationalCorrectCodInitEd/MUE.
Questions?
Email us at [email protected] or call our Provider Services Representatives at (646) 473-7160.
