Do you know that even a small mistake in a claim can trigger a denial or compliance issue for your practice? That’s why practices are readily switching to electronic claims processing, as it reduces manual entry errors and makes healthcare practices’ revenue cycle more efficient in this digital era. However, electronic claim submissions come with their own set of challenges, and one of them is identifying the correct payer ID.
But what is a payer ID, who uses it, and why is a First Health Network payer ID important for claim submissions to this national-level preferred provider organization (PPO) network? Let’s find out the details in this blog.
What is the First Health Network?
First Health Network is a PPO network that connects healthcare providers (physicians, hospitals, and clinics) with health plans, insurers, employers, and third-party administrators, under an agreement that participating members (patients) will be allowed to access medical care at lower prices. This network’s reach is usually across a broad geographic area.
First Health Network has additionally employed a range of network configurations and names over the years. For example, payer directories may contain historical references to First Health Network and names associated with its predecessor or related network arrangements, such as First Choice of the Midwest and CCN Managed Care Inc.
However, providers must not assume that all the registered patients at First Health Network have similar benefits or claims-submission instructions. It is solely dependent upon the patient’s specific member ID card, which remains one of the most important sources for identifying the First Health Network payer ID.
First Health Network Payer ID
First Health Network payer ID, also known as the Electronic Data Interchange (EDI) ID, is used as an identifier assigned to an insurance payer. Billing teams include this unique 5-digit ID on electronic claim submissions to direct the claim to the appropriate payer or claims processor for adjudication. It is a routing address informing the clearinghouse which payer to send the claim to.
First Health Network payer ID for Health First Health Plans is 95019 for both professional (CMS-1500) and institutional (UB-04) claims submitted to it. This ID guarantees that your claims are sent to the appropriate processing facility, whether you are filing commercial insurance or Medicare claims.
However, in compliance with third-party administrator (TPA) plans that use First Health as a network partner, you may occasionally require a different payer ID. So, always confirm the details of payer IDs using:
- The patient’s insurance card
- The payer portal
- First Health eligibility verification
Verifying Eligibility with First Health Network
Eligibility verification is a crucial step that should be completed before services are rendered. It helps the provider understand if the patient’s coverage is active and whether certain network criteria, authorization rules, referrals, or benefit limitations apply to the intended service.
However, having a First Health-related plan does not mean the plan will cover all services. Follow these steps to verify eligibility with the First Health Network payer.
Provider Portal
Billing staff can use First Health Network’s provider portal to access real-time data. They may use it to review eligibility, benefits, claims information, and authorization requirements.
Phone Verification
If the portal does not work or the clearinghouse data looks incomplete or outdated, you can always call the number listed on the patient’s insurance card or payer sheet. Either the network line or the plan administrator directly, depending on who’s managing the benefit, may provide you with the updated information, including the exact 5-digit First Health Network payer ID.
Clearinghouse Real-Time Eligibility (RTE)
Most medical billing systems and clearinghouses support electronic eligibility transactions. This is the fastest method to pull eligibility data directly from the payer in seconds. However, its accuracy depends on the payer and TPAs behind the First Health-priced claim keeping their data current with the clearinghouse.
Prior Authorization for First Health Network
Acquiring prior authorization before providing services is as important as verifying eligibility. Always check the authorization criteria outlined in the patient’s particular First Health Network payer plan before providing services. Keep in mind that the need for pre-authorization may change based on the service category and the patient’s plan type. Hence, providers should not assume that all First Health Network members have the same authorization rules.
But some common services may require prior authorization depending on the patient’s specific plan, such as advanced imaging procedures, surgical procedures, inpatient admissions, specialty treatments, high-cost or complex medical services, or other services identified by the patient’s specific plan. The prior authorization request may be sent through:
- The Provider Portal: It is an efficient option for online submission.
- Telephone: This allows providers to contact the department.
- Fax or Paper Form: Some plans still provide authorization forms for manual submission.
Billers must acquire authorization before providing services when the plan requires it. If they wait till the date of surgery, they may not receive it in time and face reimbursement issues later because many First Health Network payer plans treat a missing authorization as grounds for outright denial, regardless of whether the service was medically necessary.
Therefore, missing pre-authorization or submitting a request after the service has already taken place carries significant reimbursement risk.
Common Reasons First Health Network Claims Get Denied
As we have discussed, the First Health Network operates as a PPO access network rather than a direct payer. Hence, claims are sent to the insurer or TPA managing the member’s plan. The following are some challenges billing teams encounter with First Health Network payer ID and claims.
Incorrect Payer ID
Many billers send claims to the incorrect payer ID because they believe First Health is a direct payer, particularly with TPA-administered or self-funded plans. However, First Health functions as a network rather than the payer of record; one of the most frequent reasons for rejection is sending a claim to a generic First Health Network payer ID rather than the particular TPA or health plan.
TPA Payer ID Mismatches
Sometimes various clearinghouses display different IDs for the same administrator, or a plan may have moved to a new TPA without informing clearinghouses. This also leads to an out-of-date or mismatched ID and claims being routed to the wrong payer.
Missing Prior Authorization
This is one of the most common and avoidable reasons for denial. This is entirely within the practice’s control at the scheduling stage. As discussed in the pre-certification process, many plans treat a missing or late authorization as an automatic denial trigger, regardless of whether the service met medical necessity criteria.
Incorrect Claims Address
Sending a claim to the incorrect mailing or electronic submission address due to an out-of-date payer sheet is another reason for claim denial. Whereas, paper claims are less risky because they are sent directly to the address indicated on the relevant payer website or member ID card.
First Health Network Payer ID vs. Other Payer IDs
The following table is a breakdown of the First Health Network payer ID as well as routing IDs of other insurance payers. Take a look.
| Payer ID | Payer | Feature |
|---|---|---|
| 95019 | First Health Network | Its network includes First Health, First Choice of the Midwest, and Cofinity providers, covering both professional and institutional claims. |
| 07689 | First Choice Health | It is listed by First Choice Health as its WebMD Payer ID for the first health arrangement shown in its directory. |
| Varies | TPA / Other Insurance Plans | The correct electronic routing information is determined by the patient’s insurance card and payer-specific instructions. |
Final Thoughts
In the above sections, we tried to cover everything you needed to understand regarding the First Health Network payer ID. However, please understand that it is only one part of accurate claims submission because First Health Network works with different payers and plan arrangements. Therefore, providers should verify the patient’s coverage, identify the responsible payer, confirm the correct electronic routing information, and review authorization requirements before providing services.
Hopefully, by following our guide, billing teams will be able to send claims to the correct First Health Network payer ID, reduce claim denials, and improve payment turnaround. Or, they may even consider acquiring medical billing and coding services from the committed NeuraBill team if handling payer regulations and claim follow-up is taking up a lot of staff time. This will help them reduce avoidable billing errors and streamline the revenue cycle.
