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Know Your HIPAA Claims

Special rules apply to these accounts.

Service Center	Specific Billing Rules/Special Contracts
SWPA HealthChoices	In conjunction with the below special instructions, for INPATIENT claims, please provide the PA Dept of State License number in the 2310A Attending Physician Name Loop using Qualifier '0B' followed by the state assigned license number.
Claims mailed to Troy, NY
Empire/GHI	Outpatient claims mail to: ValueOptions/GHI PO Box 778 Troy, NY 12181-0778 Inpatient claims mail to: ValueOptions/GHI PO Box 539 Troy, NY 12181-0539

HIPAA 837 Special Billing Instructions for all Providers

(when using software other than EDI Claims Link for Windows) :

If the Billing Provider is the Pay-to Provider and also the Rendering Provider:

• 2010AA Billing Provider Name Loop must contain two REF elements:
  • Either Qualifier '1D' and a Medicaid Number or Qualifier 'LU' and the ValueOptions Vendor Number
  • Qualifier 'G2' and the ValueOptions Provider Number

If the Billing Provider is the Pay-to Provider but the Rendering Provider is different:

• 2010AA Billing Provider Name Loop must contain one REF element:
  • Either Qualifier '1D' and a Medicaid Number or Qualifier 'LU' and the ValueOptions Vendor Number
• 2310B Rendering Provider Name Loop must contain one REF element:
  • Qualifier 'G2' and the ValueOptions Provider Number

If the Billing Entity is not the Pay-to and the Pay-to Provider is the Rendering Provider:

• 2010AA Billing Provider Name Loop will not contain a REF element.
• 2010AB Pay-To Provider Name Loop must contain two REF elements:
  • Either Qualifier '1D' and the Medicaid Number or Qualifier 'LU' and the ValueOptions Vendor Number
  • Qualifier 'G2' and the ValueOptions Provider Number

If the Billing Entity is not the Pay-to and if the Pay-to is different than the Rendering Provider:

• 2010AA Billing Provider Name Loop will not contain a REF element.
• 2010AB Pay-To Provider Name Loop must contain one REF element.
  • Qualifier '1D' and the Medicaid Number or Qualifier 'LU' and the ValueOptions Vendor Number
• 2310B Rendering Provider Name Loop must contain one REF element:
  • Qualifier 'G2' and the ValueOptions Provider Number