Important Update
Explanation of Payments (EOPs) have been regenerated for claim processing dates January 1, 2023, through December 6, 2023, to include corrected information and additional details to help aid in processing and posting prior payments received. The contents of these EOPs are associated with a prior payment and the EOP contents may contain updated information about the payments and claims. The details can be matched to prior payments based upon the payment date included on the first summary page and/or a claim number within the details.
These EOPs are located within Zelis and are available for your practice to review or abstract, based on practice preference. We have included instructions on how to create an account with Zelis in the event you do not already have one.
If you do not wish to view the EOP within Zelis, you may also view the most recent claim status, including EOP, on our Provider Portal. The portal can be accessed via the following link: HealthTrio connect - connect Login. If you require help in registering for the provider portal, please follow the link to access training materials and the link to register: HealthTrio Provider Portal - Overview | Rise 360 (articulate.com)
If you have any questions specific to the EOP contents, please contact customer service at (855) 645-8448 or email providerservices@apex4health.com or ProviderRelations@apex4health.com.
Provider Portal Announcement
Updated Prior Authorization Forms will be posted to the Health Plan website soon. A prior authorization request form should accompany both outpatient and inpatient service requests. To prevent processing delays, ensure that the prior authorization form accompanies your service request, and is complete. Incomplete authorization request forms will not be processed.
New Claims Address Effective 1/1/2023
Memorial Hermann Health Plan Claims
PO Box 19909
Houston, TX 77224
Eligibility: Please call customer service for eligibility at (855) 645-8448 on or after 1/1/2023.
2023 Claim Processing Notice:
- Billing Address: The provider’s billing address on the claim must match the address we have on file. Please send address confirmations or questions to MHHPCredentialing@apex4health.com
- Outpatient Claims: Outpatient claims billed with dates of service starting in 2022 and ending in 2023 will need to be split on separate claim forms. One for the 2022 dates of service and one for the 2023 dates of service. Claims with date spans between 2022 and 2023 may be denied.
- NDC Requirement: For dates of service on or after January 1, 2023, all providers are required to supply the NDC when billing for injectables and other drug items. Please see the NDC Requirements Reimbursement Policy under the Reimbursement Policy section of this page.
- Taxonomy: Memorial Hermann Health Plan requires Taxonomy Codes for billing and rendering providers, when submitting claims. It is critical that the taxonomy code selected as the primary or secondary taxonomy code during a provider’s enrollment with Memorial Hermann Plan is included on all electronic and paper transactions. If a claim is submitted without the pertinent taxonomy information, the claim risks being rejected if taxonomy missing or denied or priced incorrectly if taxonomy information is incorrect.
Taxonomy Code Claim Submissions Required Field
| Memorial Health |
Electronic Claims |
CMS 1500 Form |
UB-04 Form |
| Billing Provider Taxonomy |
2000A, PRV03 |
Box 33b with qualifier ZZ |
Box 81cc with B3 |
| Rendering Provider Taxonomy (required when Rendering Provider information is submitted at the claim and/or service line level) |
2310B, PRV03 |
Box 24j with qualifier ZZ in 24i |
N/A |
| Attending Provider Taxonomy (required on Inpatient Institutional claims) |
2310A, PRV03 |
N/A |
Box 76 with qualifier |
New Texas Gold Card law streamlines prior authorizations
Attention Behavioral Health Providers/Optum Network Providers
Attention Participating Provider: Required DSNP Training
Training is offered monthly in 2023, on every 4th Thursday @ Noon CST. Please email Provider Relations at providerservices@apex4health.com for registration.
Attention: Timely Filing Reminder
With the start of a new year, we want to remind you to submit claims within the timely filing requirements. We follow the claims submission requirements set forth in the Texas Department of Insurance regulations (95 days) for Commercial plans. We follow CMS guidelines (365 days) for our Medicare Advantage plan.
Provider Manual
Provider Manual
Provider Forms
HMO Waiver of Liability Form
Appeal Reference Form
Change of Ownership Form
Request for Executed Agreement Authorization Form
Refund and Overpayment Reporting Form
Provider Change Form
PCP Change Form for Physician Offices
Sample UB Claim Form & Instructions UB-04
Sample Professional Claim Form & Instructions CMS 1500
Medical Management
Prior Authorization Form – Commercial Plans
Prior Authorization Form - MA Part C
Prior Authorization Form - Behavioral Health
2024 Prior Authorization Grid
2024 Prior Authorization Requirements
2024 Prior Authorization Code List
Texas Standard Prior Authorization Form
2022 Prior Authorization Medical Statistics
Pharmacy
Navitus Provider Portal
MA Formulary
MA Prior Authorization
Commercial Formulary
Commercial Prior Authorization
Memorial Hermann Specialty Pharmacy
Memorial Hermann Specialty Pharmacy focuses on delivering high-quality, integrated care to help your patients achieve the best
possible health:
- Knowledgeable, helpful
staff to assist with specialty medications and prior authorizations
- Timely and reliable
delivery of specialty medications from the locally based pharmacy in Katy
- Free delivery, regular
refill reminders for patients and important updates
- A pharmacy with a
direct connection to Memorial Hermann providers, hospitals and clinics
The Memorial Hermann Specialty Pharmacy Medication List is a listing by therapy of specialty medications that Memorial Hermann Specialty Pharmacy can provide or facilitate access and is subject to change. For more information about specialty medications, please visit Memorial Hermann Specialty Pharmacy.
Learn more by visiting Memorial Hermann Specialty Pharmacy and by reading their Frequently Asked Questions.
Additional Specialty Services
Lumicera Specialty Pharmacy is another alternative specialty pharmacy benefit that we offer to our members. The process to fill a prescription is simple. Call a Lumicera Patient Care Specialist at (855) 847-3553 to get started.
Please go to the Lumicera Specialty Pharmacy Frequently Asked Questions page for additional resources.