Affinity Health Plan

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  • Frequently Asked Questions for Electronic Data Interchange (EDI) Claims Submission

    • What is Affinity's Payer ID Number?

      Affinity utilizes these Payer ID Numbers:

      • 13333
      • 13334
      • 23334
      • 43324

    • When do I use Payer ID 13333?

      For all Medicare Advantage and Medicaid Advantage claims.

    • When do I use Payer ID 13334?

      For all Medicaid, Child Health Plus, and Essential Plan claims.

    • When do I use Payer ID 23334?

      For all AffinityAccess (Qualified Health Plan) claims

    • When do I use Payer ID 43324?

      For all Behavioral Health claims. You will also need to include Affinity’s plan ID of 009.

    • What are the key benefits to EDI Submission?

      There are several direct and recognizable benefits to submitting claims electronically:

      • Greater claim accuracy due to electronic edits.
      • Confirmation and rejection reports to track claim routing.
      • Reduction in accounts receivable due to more timely claims processing for submitters and receivers.
      • Reduction in the cost and time associated with hard copy printing and mail preparation.
      • HIPAA compliance. 
      • EDI filing support services offered by our clearinghouse and Affinity staff.

    • Who is my EDI contact at Affinity Health Plan?

      Please call Customer Service at 1-866-247-5678 or email us at edi@affinityplan.org.

    • Which clearinghouse does Affinity Health Plan use?

      Emdeon

    • Does Affinity Health Plan accept claims directly via website?

      Currently, Affinity does not offer direct data entry for claims and only accepts claims filed electronically via our partner clearinghouse, Emdeon.

    • What if I am not currently sending claims to Emdeon?

      If you are already sending claims through Emdeon for other payers, you do not need to contact them, just begin submitting Affinity claims electronically, following the guidelines identified in EDI Information.

      If you are NOT currently submitting claims through Emdeon for other payers, you or your billing vendor will need to establish a connection for electronic submission with them. You can contact Emdeon directly at 1-877-469-3263 for instructions and guidelines. 

    • What electronic claim formats does Affinity accept?

      Affinity will accept 837P and 837I transactions through the Emdeon clearinghouse. If you are unable to submit claims in any of the accepted formats identified in the 837P and 837I Companion Guides, please contact your billing system vendor.

    • How can I be sure Affinity is receiving our claims?

      You should routinely review and load to your practice management system the confirmation and rejection reports supplied by your vendor and Emdeon each time you transmit to Affinity. These reports should be used to compare your actual submission totals against the totals shown on the reports. They will confirm which claims have reached their destination and which claims were rejected. If you do not currently receive these reports or you are unsure how to use them, please contact your vendor.

      Regardless of your individual vendor, when you send a claim electronically to Affinity, it must be processed through Emdeon. At Emdeon, the claim goes through a set of standard edits to make sure the claim is error free. If the claim meets these standard requirements, Emdeon accepts the claim and forwards it to Affinity. If the claim is missing required information or does not meet Emdeon's edits, Emdeon rejects the claim and the claim does not reach Affinity. 

      The following are Emdeon Reports that you should check to see if your claims were passed to them. They are listed by a report code. The report code can be found in the upper left-hand corner of your report. If your claims are filed electronically to an intermediary vendor first and then passed to Emdeon, please check with your vendor to ensure you are receiving comparable reports. 

      R022 Provider Daily Statistics Report  

      This report lists the totals of claims submitted, accepted, and rejected by Emdeon for all payers for that day. Accepted claims are forwarded on to the payers, rejected claims are not forwarded. Any rejected batches or claims are listed on this report including the reason they were rejected. These claims can then be corrected and re-submitted to Emdeon. 

      R023 Provider Daily Summary  

      This summary lists number of accepted claims per batch. It also contains a Provider Totals section that shows all input, accepted, and rejected statistics for that day, month-to-date, and year-to-date. 

      R026 Daily Acceptance Report  

      This report lists the claims accepted by Emdeon and forwarded to all payers. 

      R028 Provider Monthly Summary  

      This summary contains the Month-To-Date and Year-To-Date claim totals and statistics for providers. 

    • Why is Affinity not receiving our transmission?

      This problem could result from several different areas. Please review the items below to determine the most viable solution:

      • Verify that all claims are transmitted to Affinity from both your vendor and Emdeon by reviewing your confirmation/rejection reports daily.
      • Make certain all eligible claims in your system are flagged to go out electronically to Emdeon using Affinity's Payer IDs.
      • Check with your vendor to verify they are receiving all of your claims.
      • Ask your vendor to contact Emdeon to verify that all of your claims are received by Emdeon.
      • Some vendors require an additional number for electronic routing unique to their vendor requirements or even reference the actual payer address/name information passed to determine electronic routing. Please check with your vendor to determine vendor specific edits for routing claims electronically to Affinity.

      If all of the above have been checked and verified and Affinity is still not receiving your claims, please contact Customer Service at 1-866-247-5678 or email us at: edi@affinityplan.org

    • Why is Affinity receiving paper claims from us when we transmit electronically?

      Some vendors offer a service that automatically converts electronic claims to paper if they are rejected during transmission to the next vendor (usually the Emdeon clearinghouse). Review your Emdeon rejection reports and contact your vendor to discuss how they handle rejected claims.

    • Should I submit the same claims electronically AND by paper just to be sure it is received?

      No. Please choose either paper or electronic filing, never both. Filing twice, by paper and electronic, will result in duplicated claim handling by Affinity.

    • Should I submit claims for capitated services electronically?

      Yes. Affinity Health Plan processes claims and encounters through the same system. It is important to submit claims and/or encounters for all services rendered. Affinity will continue to include these claims in the remittance advice with a message the service is covered under a capitation arrangement.

    • Does Affinity provide Electronic Remittance Advice (ERA)?

      Affinity offers an ERA/EFT solution with our partner clearinghouse, Emdeon, for our Medicaid, Family Health Plus, and Child Health Plus product lines only. Please contact Emdeon directly to enroll at http://www.emdeon.com/epayment/ or 866-506-2830. You will need to contact Emdeon directly even you use another clearinghouse besides Emdeon. The process is fast and simple and EFTs will start within the next 7 to 10 days following enrollment. It should be noted that you will continue to receive paper EOPs as well as your 835 ERA for a period of 45 days following enrollment so plan accordingly to be sure you can accept and load your ERA data.