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Providers

Claims Processing Information

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Electronic Claims Processing

You can have speed, convenience and lower administrative costs through Electronic Data Interchange (EDI) or electronic claims processing. We utilize Smart Data Solutions (SDS) as our clearinghouse.

To take advantage of this service, contact your billing software vendor and request that your claims be submitted through (SDS). You can also contact SDS directly. All trading agreements come through them exclusively. You can contact them directly at stream.support@sdata.us in order to set up a trading platform with us.

Be sure to include the following information: first name, last name, email, phone, organization name, organization NPI, organization Tax ID, and which payer claims will be submitted to:

  • Health Partners Plans Medicaid / CHIP / Jefferson Health Plans Medicare Advantage HMO / Jefferson Health Plans Individuals and Family: Payer ID# 80142
  • Jefferson Health Plans Medicare PPO: Payer ID# RP099
EDI Claims

Electronic Data Interchange (EDI) is the sending and receiving of information using computer technology. Any standard business document that one company would exchange with another, such as a purchase order, invoice, shipping schedule, inventory inquiry and claim submission, can be exchanged via EDI between the two parties, or trading partners.

The Benefits of EDI
  • Reduced administrative costs
  • Higher claim acceptance rates
  • Data moves faster and with greater accuracy
  • Increased productivity
  • Audit trail of claims submissions
  • Elimination of paper documents
  • Elimination of labor-intensive tasks, such as data entry
  • Greater accuracy of information

If you are not submitting your own claims, please forward the guide to your clearinghouse or whoever else is responsible for your transactions.

Need Help with EDI Processing? Contact Our Claims Department

Still have questions regarding EDI processing? If you are a health care professional with questions, or are interested in becoming an electronic biller, feel free to email our Claims Department (EDI) Support line at EDI@jeffersonhealthplans.com. Our EDI Analysts will be glad to contact you, typically via telephone. 

Please keep in mind, this is not the place for vendors, physicians or health care professionals to send questions regarding claim payments. If you have questions regarding claims, call our Operations Technical Support - EDI/Transaction Hotline at 1-215-991-4290 or the Provider Service Hotline at 1-888-991-9023.

Frequently Asked Questions

Contact SDS directly. All trading agreements would come through them exclusively. You can contact them directly stream.support@sdata.us.

Please contact your billing software vendor for details.

We recommend that you start by sending 20-30 claims to ensure no issues exist. We also suggest that you contact the Claims Department (EDI) Support line at EDI@jeffersonhealthplans.com after submitting the first batch of claims so that we can analyze them for any potential issues.

Email is very different from EDI. The EDI data is transmitted in a structured format, based on the use of transaction standards, which ensures that all participants use a common language.

Yes, there are two types of reports available to providers.  

  • RPT01/RPT05: This report identifies all claim rejections with invalid and/or missing data that have been sent back to the provider from SDS. Claims rejected at this level cannot be identified by Jefferson Health Plans and are rejected before reaching our claims processing system. To inquire about claim error(s) found on this report, please contact your billing software vendor.
  • RPT10/RPT11: This report identifies all claim rejections with invalid and/or missing data that have been sent back to the provider from Jefferson Health Plans. To inquire about claims errors found on this report, please contact the Claims Department (EDI) Support Line and provide the Carrier Reference Number (Car Ref #) of the error(s) in question to the representative.

The following items are required on claims sent electronically for Jefferson Health Plans members:

  • ELECTRONIC PAYOR ID for Medicare PPO: RP099
  • ELECTRONIC PAYOR ID for ALL other products (Medicaid, CHIP, Medicare HMO/DSNP, Individual and Family.-  80142 

National Provider Identifier (NPI) Failure to include this information will result in rejection of the claim. 

The National Provider Identifier is assigned to the provider by the Centers of Medicare and Medicaid Services (CMS). It is a valid 10-digit numeric value based on rules supplied by CMS.

If you do not have the appropriate equipment for electronic claims process, we suggest that you contact Smart Data Solutions (SDS), or your billing software vendor, for more information. 

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