Provider Alerts

Health Plan is happy to announce an enhancement to our EDI 837 Inbound Processing System effective September 3, 2024, aimed at improving the efficiency and accuracy of claims processing. EDI 837 is a standardized format for the electronic submission of healthcare claim information.

What’s Changing?

Our new update focuses on improving how we handle claim rejections, specifically by enhancing our system’s ability to verify member information and service dates. The key enhancements include:

1. Member Lookup Match: The upgraded system will automatically verify that the members associated with the claims are indeed covered by our health plan. This will be done through a detailed cross-check against our internal member records. This enhancement is designed to ensure that only claims for eligible members are processed, reducing the chances of errors and improving the accuracy of claims handling.
2. Date of Service Validation: In addition to verifying member eligibility, the system will now also ensure that the date of service on the claim aligns with the member’s eligibility period. This means that claims will only be processed if the service date falls within the member’s active coverage period, further reducing the risk of claim rejections due to eligibility discrepancies.

What Does This Mean for You?

• Fewer Claim Rejections: With these improvements, you can expect a decrease in claim rejections related to member eligibility and service date issues. This should lead to a smoother claims submission process and faster resolution of claims.
• Improved Processing Efficiency: The automation and enhancements will lead to more efficient processing of your claims, reducing the need for manual intervention and follow-up.

Next Steps:

No action is required on your part. The transition will be seamless, and you should not experience any interruptions during or after the release. However, we encourage you to monitor your claims closely in the days following the update to ensure that everything is functioning as expected.

We are committed to continuously enhancing our systems to better serve you and our members.

If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website WWW.HPSJ-MVHP.ORG