Prompt Payment Guidelines

Date Issued: 7/21/2014

All Non-Medicare Claims

EmblemHealth adheres to New York State law for the prompt payment of claims:

  • 30 days for electronic claims
  • 45 days for paper claims

Duplicate claims should not be submitted unless the mandated processing time has passed.

All Medicare Claims

EmblemHealth adheres to Centers for Medicare & Medicaid Services rules and regulations for prompt claims payment:

  • 95 percent of clean claims processed within 30 days
  • All other claims processed within 60 days

For clean claims not processed within 30 days, EmblemHealth pays interest at the prevailing rate under Medicare regulations. Duplicate claims should not be submitted unless the mandated processing time has elapsed.

Both Medicare and Non-Medicare Claims

EmblemHealth does not pay claims submitted later than 120 days after the date of service or later than 90 days after the date the Explanation of Benefits was issued by the primary payer in the case of a coordination of benefits issue. Exception: The late submission is the result of an unusual occurrence and the provider has a pattern of timely submission.

Claims submitted more than 365 days after the service date are not paid under any circumstances.