NY Manual
SHP Manual

SHP Provider Manual
5.1 Billing Reimbursement Procedures | 5.1b Requests for Review and Reconsideration of a Claim

5.1 a Claims Submission Procedures

Submitting Claims Electronically

Senior Health Partners utilizes the Emdeon (WebMD) clearinghouse for all electronic claims. Claims submitted electronically on the CMS 1500 and UB 04 receive a status report indicating which claims were accepted, rejected and/or pending, and the amount paid on the claim once it has been finalized. Claims submitted electronically must include:

1.        Senior Health Partners Payer ID Number 80141

2.        Complete Senior Health Partner Member’s CIN ID number

3.        A National Provider Identifier (NPI) should reside in:

           •   837 Professional (CMS)-Loop 2310B Rendering Provider Secondary ID, Segment/Element NM109. NM 108 must qualify with an XX (NPI)

           •   837 Institutional (UB04)-Loop 201 AA Billing Provider, Segment/Element NM 109. NM 108 must qualify with an XX (NPI)

To sign up for electronic billing providers must contact their software vendor and request that their Senior Health Partners claims be submitted through Emdeon. Providers can also direct their current clearinghouse to forward claims to Emdeon. Please contact Emdeon at (800) 845-6592 for information on how to set up electronic billing.

 If you have any questions regarding claims issues, please call (877) 737-2693. Representatives are available Monday-Friday, 9am-5pm.  

Submitting Paper Claims

All paper claims should be submitted to:  

                                                Senior Health Partners Claim Department 
                                                P. O. Box 958439 
                                                Lake Mary, FL 32795-8439 

All Paper claims should include the National Provider Identifier (NPI) and well as the Senior Health Partners-assigned Provider ID Number, (the latter is not required for electronic claims). The Senior Health Provider ID is a unique provider number for each practice site.  

Timely Claim Submission

In-network providers must file claims within 180 days of the date of service. Out-of-network providers must file claims according to Medicare fee-for-service rules. 

Authorizations: All Senior Health Partners network providers and Out of Network Providers will receive an authorization for covered services EXCEPT FOR Dentistry, Optometry, Audiology and Podiatry. Except for emergency services and treatment of urgent medical conditions, providers are required to receive authorization prior to providing services to Senior Health Partner members, whether or not Senior Health Partners providers referred the members. Contact Senior Health Partner’s Care Management Team at (212) 324-2600 for questions related to care management and service authorizations. 

Billing Senior Health Partners

All payments for services provided to Senior Health Partners members constitute payment in full. Providers may not balance bill members for the difference between their actual charges and the reimbursed amounts; any such billing is violation of the provider’s contract with Senior Health Partners and applicable New York State Law. Where appropriate, Senior Health Partners will refer providers who willfully or repeatedly bill members to the relevant regulatory agency for further action. 

Reference: Tab 3 – Sample Blank HCFA Form 1500