• Claims

  • Claims Submission

    In an effort to provide prompt and accurate claims payment, Affinity encourages providers to submit claims electronically. We will also accept paper claims. Please review the information below to assist you with process for both submission options.

    Submitting Claims Electronically

    For efficient and quick processing of your claims, Affinity recommends that you submit your claims via Electronic Data Interchange (EDI). If you are already submitting claims electronically to Affinity, you may want to reference our 837P and 837I Companion Guides and other EDI information. If you need help, please contact Affinity Health Plan's EDI Department at edi@affinityplan.org.

    For Affinity’s NPI requirements on claims submission or to advise us of your NPI(s).

    For claims inquires and/or appeals, please submit all written requests to:
    Affinity Health Plan
    Claims Department
    PO Box 812 Gracie Station
    New York, NY, 10028

    For more information on claims submission, please choose one of the following options:

    • Review our EDI Frequently Asked Questions (FAQs)
    • For inquiries on the process for submitting EDI claims through Emdeon, our clearing house, send an e-mail to edi@affinityplan.org You can also access the Emdeon web site at www.emdeon.com
    • For all general claims inquiries, call Customer Service at 866.247.5678. A representative will respond to your inquiry within one business day
    • Non-Participating Provider Verification
      In order to process your most recent authorization and/or claim, please complete and fax the non-participating provider verification form to Affinity at 718.536.3315 within three (3) days of receipt of your authorization. In addition, please attach a W9 form.

      If your claims were rejected by Affinity Health Plan via Emdeon with the Affinity Code of “86” (please go to Claims Status Codes link for details) your information can then be loaded into our systems within 10 business days of receipt of the verification form. After submitting this form to Affinity, you may resubmit your claims electronically after 10 business days.
    • Waiver of Liability

    Submitting Paper Claims by Mail

    You can download paper claim forms here: CMS-1500 (Professional) and UB04 (Institutional). These forms are also available through various vendors, the American Medical Association (AMA) or the U.S. Government Printing Office.

    Addresses for paper claims:

    For Qualified Health Plans (AffinityAccess) Members
    AffinityAccess Claims Unit
    PO Box 981650
    El Paso, TX 79998 – 1650

    For Child Health Plus and Medicaid Members
    Affinity Health Plan
    PO Box 981726
    El Paso, TX 79998 – 1726

    For Affinity Medicare Members
    PO Box 4018
    Scranton, PA 18505 – 6018

    Submission Guidelines

    In order to most efficiently and accurately process your claims, please review the following guidelines.

    DO:

    • Submit only original CMS1500/UB04 claim forms
    • Align all characters in their proper sections and designated fields
    • Type or machine-print all mandated claim fields
    • Make sure all of the mandatory fields are completed and legible
    • Submit clean claims forms without smudges or discolorations
    • If using carbon forms, send only the original or top copy
    • Make sure the information entered on the claim form is readable(Claims that are too light may be returned)
    • Submit only six line items per claim
    • If you make request for a claim review, please submit in a separate letter and not on the claim form

    DON'T:

    • Make handwritten corrections
    • Use red ink
    • Squeeze two lines of information on one line
    • Place extra writing across item 24
    • Place Post-it notes or stapled notes on the form
    • Use hand stamps
    • Use highlighters
    • Use special characters, dollar signs, decimals, dashes or other symbols

    Reimbursement Forms

    Sterilization Consent Form
    To receive reimbursement for sterilization procedures, please fax completed form and associated claim(s), according to Affinity guidelines, to Affinity’s Medical Management Pre-Certification Department at 718.794.7822 or 718.536.3329

    Acknowledgement of Receipt of Hysterectomy Information Form
    To receive reimbursement for hysterectomy procedures, please fax completed form and associated claim(s), according to Affinity guidelines, to Affinity’s Medical Management Pre-Certification Department at 718.794.7822 or 718.536.3329

    You may also access these forms from the New York State Department of Health's Web site by health.state.ny.us/health_care/.

    Electronic services

    Affinity Health Plan now supports 835 remittance processing through Emdeon Payment Services.