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Claims

Our internal processes for claims payment ensure the highest level of accuracy. Health Choice Insurance Co. (Health Choice) strives to adjudicate all claims as quickly as possible, but have up to 30 days to process a clean claim. For more information please see Chapter 11 of the Provider Manual

Any reoccurring or escalated issues can be addressed by scheduling an appointment with a provider liaison offered through our Claims department. All claims will be reviewed to see if member’s eligibility has changed to or from a Marketplace plan and will be automatically processed by the appropriate line of business. The process will appear seamless to your office, reducing your administrative burden. In addition, Health Choice offers a provider educator that can assist with a billing and coding seminar in a one-on-one setting.

Health choice is an HMO and does not offer any out-of-network benefits except in the case of emergencies.

In-network providers rendering services that have an appropriate referral and/or prior authorization may not balance bill the member. All specialist claims must have a referral from the member’s primary care physician (PCP) on file with Health Choice otherwise the claim will be denied. All services listed on the prior authorization grid must have an approved prior authorization along with the referral otherwise claims will be denied. For the current prior authorization grid please click here.

Electronic Data Interchange (EDI)

At Health Choice Insurance Co., we will accept both electronic and paper claims from providers. To help you improve your efficiency so that you can focus on patient care, we encourage you to submit claims electronically by utilizing Electronic Data Interchange (EDI).

The benefits of EDI are:

  • Faster Transaction time and payment.
  • Reduced operational costs compared to paper claims (printing, collating, postage, etc.).
  • Increased accuracy resulting from validation of data elements.
  • Reduced adjustments.

Health Choice Insurance Co. is fully 5010-compliant, and can also accept 4010 claims. To better serve you, we are affiliated with Emdeon.

Name Phone Number Transaction Type/Format Payer ID
Emdeon
 
 
 
1-877-469-3263
 
 
 
HCFA 1500 - Professional (837P)
UB 92 - Institutional (837I)
Claims Status Inquiry/Response (276/277)
46221
46221
HCICO
Emdeon 1-866-506-2830 Electronic Remittance Advice (835) 15081

For questions regarding claims, call Health Choice Insurance Co. toll-free at 1-855-452-4242.

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