Claims and Reimbursement

The 1199SEIU Benefit Funds strive to pay clean, electronic claims within 30 days of receipt and clean, non-electronic claims within 45 days of receipt. “Clean claims” will be defined as those claims that satisfy the definition of clean claims as specified in section 80.2 of the Medicare Claims Processing Manual. A clean claim means either a properly completed UB-04 or CMS-I500 that is submitted for payment promptly and which includes all information needed to process the claim, including coordination of benefits information required by the Benefit Funds.

All claims should include the member ID number, the Benefit Funds’ payer identification number and the national provider identifier (NPI).

Timeframe for Claims Submission

Participating providers must submit clean claims within 90 days of the date of service or the date of discharge for inpatient services. The 1199SEIU Benefit Funds may deny claims submitted more than one year after the date of service or discharge unless proof of timely filing can be established.

Claims Submission

Providers must submit claims electronically unless the claim requires attachments or documentation that cannot be transmitted electronically. Electronic claims submission is a secure vehicle to transmit claims information to the 1199SEIU Benefit Funds.

The Benefit Funds accept professional service (837P) and inpatient and outpatient hospital claims (837I) in an electronic format via Inovalon. To establish an account with Inovalon, call (800) 548-2890 or visit the Inovalon website, where you can complete and submit an intake form.

Payer Identification Number

To submit electronic claims, providers must use the 1199SEIU Benefit Funds’ payer identification number, which is 13162.

National Provider Identifier

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires healthcare providers to apply for a federally assigned national provider identifier (NPI). Providers were federally mandated to begin using the NPI on May 23, 2007. The use of the NPI standardizes provider identification nationally and makes it easier to identify healthcare transactions, including claims, eligibility inquiries, claim status inquiries and referrals.

Use your NPI on all claims and correspondence with the 1199SEIU Benefit Funds.

Paper Claims Submission

You may submit your paper claims to the 1199SEIU Benefit Funds as follows:

For medical claims: 1199SEIU Benefit Funds Attn: Medical Claims PO Box 1007 New York, NY 10108-1007

For hospital claims: 1199SEIU Benefit Funds Attn: Hospital Claims PO Box 933 New York, NY 10108-0933

Claim Editing Software Programs

Providers must report correct CPT, HCPCS and ICD10 codes with applicable modifiers (when appropriate), which are in accordance with the reporting guidelines and instructions published by the American Medical Association (AMA), CPT manual and HCPCS publications.

The 1199SEIU Benefit Funds utilize Lyric’s clinically based claims editing program to help ensure that our code and claim editing rules are accurate and consistent with industry standard practices. Doing so enables us to process claims efficiently and provide accurate reimbursement. In addition to our customized coding policies, the Benefit Funds adhere to coding guidelines issued by, among others, the American Medical Association (AMA); Centers for Medicare and Medicaid Services (CMS); National Correct Coding Initiative (NCCI); and CPT Assistant, as well as some National Specialty Societies. With professional and outpatient facility claims, the Lyric claims editing program is used to evaluate and identify inconsistencies such as unbundling of services; services reported that may be incidental or mutually exclusive or designated as Medicare medically unlikely edits (MUEs); and/or incorrect CPT code/modifier combinations. The program is updated quarterly; currently, we use Lyric, formerly ClaimsXten. See our Claim Submission and Billing page for additional information.

The Benefit Funds reference the most recent versions for CPT-4, HCPCS Level II and ICD10 codes.

Electronic Fund Transfer

Electronic fund transfer (EFT) payments

The 1199SEIU Benefit Funds have selected Zelis as their electronic payment and remittance reporting provider. Zelis e-payments for medical providers replace paper-based claims payments with electronic funds transfer (EFT) payments that are directly deposited into your bank account. There is no cost to you to use the Funds-sponsored Zelis plan, and enrollment is free. You can use Zelis’s proprietary e-payment provider portal to manage Funds payments.  

Get paid faster with EFT payments

With EFT payments, you can accelerate your reimbursement cycle since you don’t have to wait for your checks to arrive in the mail. Plus, it eliminates manual processes like sorting and opening mail, reconciling paper-based claims payments, creating deposit tickets and making trips to the bank.

Simplify reconciliation

Once enrolled in Zelis e-payments, the Benefit Funds will generate a downloadable HIPAA-formatted 835 ERA file through your respective clearinghouse. You can also access the Zelis Provider Portal to view and print EOP images.

Note: Your basic enrollment with the Funds-sponsored Zelis e-payment tool includes access to the standard version of Zelis’s e-payment manager, offering the capability to search, view, print and download EOP information for Funds payments. You can upgrade to the premium version, which includes more robust capabilities across multiple payers, for a fee.

Enroll in Zelis

To enroll in Zelis, visit their enrollment site and select the 1199SEIU Funds logo. If you have any questions, please call (877) 828-8770.

Provider Remittance

All claim determinations are communicated to providers via a Provider Remittance Form, which provides a detailed explanation of how the claim was paid, the payment amount, check number and reasons for denial(s), if any.

Claims Status

Providers may check medical and hospital claims status by:

• Visiting NaviNet.net or
• Calling the 1199SEIU Benefit Funds’ IVR system at (888) 819-1199.

Overpayment Recovery Program

The 1199SEIU Benefit Funds will notify the provider in writing if a claim overpayment has been made to such provider. The provider is expected to reimburse the Benefit Funds within 30 days of receiving the Benefit Funds’ notification. An overpayment by the Benefit Funds to the provider should be reimbursed by check payable to the applicable Benefit Fund. A copy of the notification letter should accompany the refund check to ensure proper credit of the refund. The refund should be mailed to:

1199SEIU Benefit and Pension Funds
P.O. Box 837
New York, NY 10108-0837

Providers should immediately contact the Benefit Funds’ Recovery Unit in writing (using the address below) to obtain additional details regarding an overpayment; to clarify discrepancies; or to arrange repayment terms. If after 30 days from the provider’s receipt of the Benefit Funds’ request for reimbursement the overpayment has not been reimbursed by the provider or arrangements have not been made to refund the overpayment, we will regard this as an election to deduct the overpayment via a claim reversal or from future claim payment, and we will collect the overpayment in this manner.

1199SEIU Benefit and Pension Funds
Attn: Recovery Unit
498 Seventh Avenue
New York, NY 10018

Time limits: It is the Benefit Funds’ policy to pursue collection of claim overpayments for six years from the date the overpayment is discovered. State insurance laws, which impose time limits on overpayment recovery by insurance companies, do not apply to the Benefit Funds because the Benefit Funds are not insurance companies.