Electronic Claims
We accept all claims submissions electronically through Inovalon FKA Ability. Our payor number is 13162.
For registration or enrollment, call (800) 548-2890 or complete and submit an intake form and an Inovalon provider representative will contact you.
Paper Claims
Send UB-04 claims to P.O. Box 933, New York, NY 10108-0933
Send CMS 1500 claims to P.O. Box 1007, New York, NY 10108-1007.
The Benefit Funds do not administer dental benefits for 1199SEIU members. Please review your 1199SEIU patient’s dental identification card to identify the carrier and locate associated contact information for that carrier.
Electronic Payments
With ePayment, you can accelerate your reimbursement cycle since you don’t have to wait for checks to arrive in the mail. In addition, ePayment eliminates manual processes, such as sorting and opening mail and reconciling paper-based claims payments.
The Benefit Funds have selected Zelis for electronic payment and electronic remittance advice distribution. There is no cost to you to enroll in the Benefit Funds’-sponsored Zelis ePayment center portal. You can also log into Zelis’ proprietary ePayment provider portal to manage payments.
Telephone: (877) 828-8770
Claims Editing Rules
The Benefit Funds’ comprehensive claims auding software was upgraded in August 2024 to Lyric’s ClaimsXten™ Solution version 6.2.2.79. Lyric uses the National Correct Coding Initiative (NCCI), which includes the Procedure-to-Procedure and Outpatient Code Editor edits, as well as Medically Unlikely Edits (MUEs). The Centers for Medicare & Medicaid Services (CMS) developed NCCI to promote correct coding methodologies and limit improper coding and other inappropriate reimbursements. All code and NCCI data are updated quarterly, at a minimum. For additional information on NCCI, please visit the CMS website.
Lyric’s ClaimsXten Solution FAQs
Lyric MUE Practitioner Rule Education
To ensure that professional claims billed on the CMS 1500 form are paid accurately and according to standard Medicare claims rules, starting on October 1, 2022, the Benefit Funds have been applying the Medicare MUEs for Practitioners in the Lyric audit application. The Benefit Funds are adding the standard Medicare claims coding rule to audit professional claims for the clinically determined standard practitioner MUEs for a date of service (DOS).
Lyric Medicare MUE Practitioner DOS (MCARE_MUE_PRACTITIONER) rule for professional claims identifies claim lines where the number of Common Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) units billed exceeds the clinically defined maximum when reported by the same provider for the same member on the same DOS. The rule takes the MUE adjudication indicator (MAI) into account.
The MAIs are as follows:
- MAI 1 = claim line edits
- MAI 2 = DOS edits (based on policy)
- MAI 3 = DOS edits (based on clinical benchmarks)
Lyric directly uploads CMS MUE values from Medicare’s NCCI edits.
Typically, services that are not covered, separately payable or reasonable, and are bundled, necessary or statutorily excluded, are assigned an MUE value of zero (0) by CMS. Some drug codes may also be assigned an MUE value of zero.
For codes with a CMS MUE value of zero, the following code rules have a default frequency value based on anatomic considerations, CPT/HCPCS code descriptors, CPT instructions, CMS policies/MUE values, the nature of the service/procedure, the nature of analyte, the nature of equipment and clinical judgment:
- American Medical Association
- Centers for Medicare & Medicaid Services
- McKesson
Codes with no default frequency value, such as those in the Base Code Quantity rule, will be excluded from unit auditing.
For additional information on MUEs, please visit the CMS website.
Questions?
Email [email protected] or call our Provider Services representatives at (646) 473-7160.
