All claims must be submitted to HNE on either a CMS-1500 form (formerly HCFA-1500 form) or a UB-92 form.  All PCPs, specialists and ancillary providers must submit itemized claims to the HNE Claims Department.  Claims must be submitted to HNE within 180 days from the date of service or the date of discharge from a facility; or within the time period specified by contract.  In the case of Coordination of Benefits (COB) with another payer, the claim must be submitted to HNE within six months of the date of payment or denial by the primary carrier. If HNE does not recieve a bill within the specified time period, it will be denied for exceeding the claims filing limit.  Providers may not bill members for the services denied payment for untimely submission.

The filing limit also applies to the resubmission of claims.  If a claim is denied for no referral, invalid referral incorrect code, etc., and the provider resubmits the claim with the correct information, it must be received by HNE within the filing limit of the original date of service.  Providers should also be aware that the filing limit applies when utilizing the services of a billing agent.  The 180 day filing limit also applies to the submission of the In-Plan Specialty Referral Form.

If COB is involved and HNE is secondary, a copy of the EOB from the primary insurer should be attached to the claim. 

Specialist and ancillary provider claims that require a referral must be accompanied by an appropriate written In-Plan Specialty Referral Form from the member’s PCP or another plan-contracted physician.  The provider rendering the service is responsible for submitting the referral to HNE.

In-Plan Specialty Referral Forms can be mailed, submitted on-line using HNEDirect, or if the provider submits claims electronically, they can be faxed to HNE at 413.734.7539.