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  • Claims > Coordination of Benefits

    EmblemHealth will not deny a claim, in whole or in part, on the basis that it is coordinating benefits and the member has other health insurance coverage, unless we have a reasonable basis to believe that the member has other health insurance coverage that is primary for the claimed benefit. If EmblemHealth requests and does not receive information regarding other coverage from the member within 45, then we will adjudicate the claim.

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    Glossary terms found on this page:

    Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    When a member is covered by more than one benefit plan, with both providing similar benefits, EmblemHealth coordinates with the other carrier to ensure appropriate reimbursement. Also called COB.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

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