Billing & Claims
Electronic Billing
Billing Provider
Individual Providers
- Enter each part of the name in separate fields
- Use format: LASTNAME FIRSTNAME MIDDLEINITIAL (not required) Title (not recommended) – so the provider name is not all in the Last Name field.
- No punctuation
- Example EDI: NM1*85*1*SMITH*JOHN*A**
- If your software does not allow name separation, please contact MHP Provider Services to discuss options.
Companies/Groups
- Enter as much of the full name as possible in the Last Name field.
- Use format: GROUPNAME
- No punctuation
- Example EDI: NM1*85*2*SMITH RADIOLOGY GR****
Billing Provider Street Address
- All Providers – 999 S ANYWHERE ST or PO BOX 999
- No punctuation. N, E, S, W, NE, SW, etc. Standard USPS street-type abbreviations.
- No additional address information required or processed for street.
Billing Provider City, State, Zip
- Full city name as space allows and standard USPS 2-digit state abbreviation.
- Important: 5-digit Zip Code
- Each in a separate field.
Member Group Number
- Member Group Number must be filled. Can be a default of: 999999
- MEMBER – IL (same for QC dependent as applicable)
Member Name
- Enter each part of the name in separate fields
- Use format: LASTNAME FIRSTNAME MIDDLEINITIAL
- NOTE: Incorrect spelling of name can cause rejection.
Medicaid ID
- Member Identification # – MI – The member’s Medicaid ID # must be ten (10) digits or it will be REJECTED
Commercial ID
- Member Identification # – MI – All must be exactly 7 digits or it will be REJECTED
Member Street, City, State, Zip
- All Members – 999 S ANYWHERE ST or PO BOX 999
- No punctuation. N, E, S, W, NE, SW, etc. Standard USPS street-type abbreviations.
- No additional address information required or processed for street.
Member Date of Birth (and any other date)
- YYYYMMDD – no punctuation
- Example: 20030214
Claims Detail
- Units – Units value cannot be zero (0).
Payer IDs
MHP receives EDI claims from our clearinghouse, ENS Optum Insight. Our Payer IDs for electronic claims are:
Alternate Providers
Alternate Provider Name
- Individual Providers – Enter each part of the name in separate fields
- Use format LASTNAME FIRSTNAME MIDDLEINITIAL (not required) and Title (not recommended) so the provider name is not all in the Last Name field.
- No punctuation
Companies/Groups
- Enter as much of the full name as possible in the Last Name field
Alternate Provider Street Address – where applicable
- All Providers – 999 S ANYWHERE ST or PO BOX 999
- No punctuation. N, E, S, W, NE, SW, etc. Standard USPS street-type abbreviations.
- No additional address information required or processed for street.
Alternate Provider City, State, Zip – where applicable
- Full City name as space allows, and standard USPS 2-digit state abbreviation.
- Important: 5-digit Zip Code
- Each in a separate field.
McLaren Health Plan utilizes ENS Optum Insight as its preferred vendor for EDI claims submissions. To become a customer of ENS Optum Insight, or if you are already a customer and are having difficulty submitting claims electronically, please contact the ENS Optum Insight Services team at inform@optum.com. ENS Optum Insight has affiliations with the following clearinghouses:
- Availity
- ClaimLynx
- Claim Logic
- CPSI
- Gateway EDI
- MedAvant
- Medical Claim Corp
- Payer Path/MISYS
- PerSe
- Relay Health (McKesson)
- Quadax
- SSI Group
- ZirMed
If you are a current customer of any of the above listed clearinghouses, your EDI claims will be routed through ENS Optum Insight, and no action is required.
If you have questions about the status of claim, contact Customer Service at (888) 327-0671.
Claims Adjustments
Claims Status Form
McLaren Health Advantage Eligibility and Claims Information
Please verify eligibility and coverage on the McLaren Connect Portal or contact Customer Service at 888-327-0671.
The member’s ID card will list office visit copays. Members are aware they are required to pay this amount and you should collect it at each visit.
You can bill the patient for non-covered services when they have been informed prior to receiving the service that it is not covered by their McLaren Health Advantage benefit. For further information on services that are not covered, call Provider Relations at 888-327‑0671 (TTY: 711).
McLaren Health Advantage accepts both paper and electronic claims. Follow the CMS requirements for paper claims using the CMS 1500 form and mail to:
McLaren Health Advantage
P.O. Box 1511
Flint, Michigan 48501-1511
For EDI claims, McLaren Health Advantage uses Netwerkes as its EDI gateway clearinghouse. For information on how your office can submit electronic claims, contact Netwerkes at payersupport@netwerkes.com (put MCLAREN in the subject line), or call Netwerkes at 262-523‑3600 and ask for the Payer Services team. McLaren Health Advantage’s EDI payer ID is 38338.
Contracted providers are paid according to the McLaren Health Advantage fee schedule.
For most of the services you provide, you must submit the claim within one year of the date of service, including coordination of benefits claims. If you experience a change in your billing service, have written, documented computer problems or other extenuating circumstances, please contact our Provider Relations department at 888-327‑0671 (TTY: 711). Negligence is not considered a valid exception. If you must re-submit a claim, they are accepted for the following situations:
- Claims requiring special consideration (i.e., referral or coding problems, special requests or adjustment)
- Must include documentation that it is a re-bill or second submission
- Must include all codes and charges, not just additional or corrected information. Please note on the claim it is a re-bill for additional consideration.
If you have not received your claims payment after 45 days, please contact Provider Relations to status your claims.
Hospital Readmissions
In-Office Laboratory Billable Procedures
Physician Administered Drugs and NDC Reporting
Out-of-Network Provider Payment Methodology