What happen when you submit the claims electronically - Horizon NJ

Electronic Claim Flow Description

In order to send claims electronically to Horizon NJ Health, all EDI claims must first be forwarded to Emdeon using payor number 22326. This can be completed via a direct submission or through another EDI clearinghouse or vendor.

Once Emdeon receives the transmitted claims, they are validated against Emdeon’s proprietary specifications and Horizon NJ Health specific requirements. Claims not meeting the requirements are immediately rejected and sent back to the sender via an Emdeon error report. The name of this report can vary based upon the physician’s contract with their intermediate EDI
vendor or Emdeon.

Claims are then passed to Horizon NJ Health and Emdeon returns a conditional acceptance report to the sender immediately. Claims forwarded to Horizon NJ Health by Emdeon are immediately validated against physician and member eligibility records. Claims that do not meet this requirement are rejected and sent back to Emdeon, which also forwards this rejection to its trading partner – the intermediate EDI vendor or directly to the hospital, physician or health care professional. Claims passing eligibility requirements are then passed to the claim processing queues. Claims are not considered received under timely filing guidelines if rejected for missing or invalid provider or member
data.

Hospitals, physicians and health care professionals are responsible for verification of EDI claims receipts. Acknowledgements for accepted or rejected claims received from Emdeon or other contracted vendors, must be reviewed and validated against transmittal records daily.

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