EDI and Claims Submission

 

Claims shall be submitted on the standard CMS 1500 or UB 92 forms or electronically through a national clearinghouse such as WebMD/Emdeon.

Providers must submit claims within 90 days of service to be considered for payment for Primary PhysicianCare members. All claims which are not complete will be denied and the denial code on the Provider’s explanation of payment will indicate what information is necessary to reprocess the claim.

Providers must also ascertain from the patient at the time of the initial visit whether an injury is work related or caused by a third party, such as an automobile accident. If an injury is work related or caused by a third party, the Provider agrees to relay this information to Primary PhysicianCare as soon as possible. This information is required to determine if Workers’ Compensation insurance applies and if Coordination of Benefits or subrogation rights should be invoked.

To ensure prompt payment, please ensure all pertinent information is on the claim form:

A Provider name must be listed in Item 31 on the claim form.

The Facility name needs to be listed in Item 33 on the claim form.

 

Electronic Claims Submission

Primary PhysicianCare uses Emdeon (WebMD) for electronic claims receipt.

Primary PhysicianCare’s payer ID# is 56144.

Please keep in mind the following information needs to be accurate on the Primary PhysicianCare member’s claim form to ensure electronic claims are properly loaded into our system:

• Member’s group number
• Member’s date of birth
• Member’s identification (ID) number
• Member’s gender