Frequently Asked Questions
- What is the billing process?
- What information is required on my claim?
- How will my claim be paid?
- What portion is the insured responsible for paying?
- What if I disagree with the way my claim is paid?
- To which providers and facilities may I refer my patients?
- How do I become a participating provider with EMI Health?
- What is accreditation and why is it necessary?
- Can I be paid by electronic funds transfer (EFT)?
What is the billing process?
Answer: We prefer that you send your claims through Electronic Data Interchange (EDI). EDI claims have a faster processing time than paper claims, and there is a reduced chance of error. EMI Health works with all of the major clearinghouses. Of course, you may also submit EDI claims directly through the Utah Health Information Network (UHIN). If you are not yet set up to send claims through EDI, you will need to obtain a trading partner number from UHIN. Once you've received that number, you may begin submitting EDI claims to EMI Health's trading partner number HT000214-001. Test claims are not required.
What information is required on my claim?
Answer: Please refer to the ADA or CMS standards for information regarding what is required on your form. If you are not using EDI, your office staff must use the most current ADA, CMS-1500, or UB92 universal claim forms. EMI Health will not accept super bills.
How will my claim be paid?
Answer: The claim will be paid according to the policyholder's contract and the EMI Health Maximum Allowable Charge.
What portion is the insured responsible for paying?
Answer: The insured pays the difference between the allowable charge and the amount EMI Health pays. If the provider is participating, any balance in excess of the EMI Health Maximum Allowable Charge will be adjusted by the provider. This amount will be outlined on your explanation of payment, under the "Insured Pays" column.
What if I disagree with the way my claim is paid?
Answer: You may request a review of any adverse claim decision by following the claims review procedure.
To which providers and facilities may I refer my patients?
Answer: EMI Health's insureds will receive maximum benefits, with less out-of-pocket expense when they are referred to participating facilities and specialists. You may access the most up-to-date provider listing here. EMI Health does not cover non-accredited facilities.
How do I become a participating provider with EMI Health?
To become a participating provider with EMI Health, each provider must go through a credentialing process to ensure he or she meets all requirements set by EMI Health. To apply for credentialing, providers must have a professional license, Certificate of Insurance (COI), Drug Enforcement Administration (DEA) License, and applicable board certifications. Medical providers must have Active Privileges at a participating facility proximate to the provider's practice location.
All providers must be individually credentialed and submitting claims under their own National Provider Identifier (NPI) and associated Tax Identification Number (TIN). To be listed as a specialist, medical providers must be board certified in that specialty by the applicable certifying board. Dentists must have completed a residency program in the applicable specialty.
Once a provider meets all credentialing criteria, EMI Health requires a signed agreement for each TIN under which the provider would like to participate in the network. The provider is required to sign each agreement. For a provider to be considered participating at any given location, that location must be included in EMI Health's system. Providers are responsible to notify EMI Health of all locations at which they would like to participate on the network.
For more information, or to request a credentialing packet, contact the provider relations representative in your area.
What is accreditation and why is it necessary?
Accreditation is a process of review that allows healthcare facilities to demonstrate their ability to meet standards established by a recognized accreditation organization. The accreditation review process looks at organizational structure, policies and procedures, and compliance with state and federal laws, with a focus on patient safety and quality of care. Achieving accreditation reflects a high level of performance and patient care. While a facility may not be legally required to obtain accreditation, EMI Health requires accreditation in order to receive payment from its health plans.
Can I be paid by electronic funds transfer (EFT)?
Yes, EMI Health is pleased to offer the convenience, savings, and security of having your claims payments remitted electronically to your bank account (electronic funds transfer). However, in order to enroll in this paperless method of payment, you must first be receiving Electronic Remittance Advices (ERAs or 835s) from EMI Health through your clearinghouse or UHIN. Once you enroll in this paperless method of payment, you will no longer receive paper Explanations of Payment (EOPs). If you are using the EOPs to apply payments to your patients' accounts, you are not ready to enroll in EFT with EMI Health.