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  • Podiatry > Posting Procedure for Participating Practitioners

    Please note that the following posting procedures for your accounts receivable are recommended for your use. Actual accounting policies for each practitioner's office may differ.

    Collection of Patient Liabilities (Copayments, Coinsurance Amounts)

    Under the Market Share Payment program, office staff should collect any copayment, coinsurance and other applicable fees for service payments from patients. In addition, any coordination of benefits information should be collected from the patient. Office staff will need to post the amounts collected from the patient.

    Upon Receipt of Remittance Advice

    A remittance advice is a financial statement that EmblemHealth sends to practitioners to reconcile accounts, explain approved charges, and review claims disbursements and member payment responsibilities. Each advice statement should be reviewed in order to determine that all submitted claims have been processed and that action has been taken on these claims.

    For patients generating Market Share Program payments, a remittance advice will be sent showing the amount paid and the original claim that generated the creation of a Market Share Point. Adjustments made to these payment amounts after the original payment processing will be included on a new remittance advice.

    When Services Are Provided to Patients Under a Market Share Payment Contact Point

    All patient service claims provided during each member's Market Share Payment program six-month time period will generate a remittance advice from EmblemHealth indicating that the patient services were compensated under a previous contact point and will reference the claim that generated the original Market Share Payment. The participating podiatrist, as previously paid in full, should write off these subsequent services.

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    Glossary terms found on this page:

    An activity of EmblemHealth or its subcontractor that results in:

    • Denial or limited authorization of a service authorization request, including the type or level of service
    • Reduction, suspension or termination of a previously authorized service
    • Denial, in whole or in part, of payment for a service
    • Failure to provide services in a timely manner
    • Failure of EmblemHealth to act within the time frames for resolution and notification of determinations regarding complaints, action appeals and complaint appeals

    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.

    A percentage of the allowed charge that is payable by the member, not EmblemHealth, for covered services rendered by an out-of-network provider. After the member has met his or her deductible, EmblemHealth will pay a percentage of the allowed charge for those covered services in accordance with the member's benefit program. The member is responsible to pay the remaining percentage of the allowed charge. This remaining percentage is the coinsurance charge.

    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.

    The fixed dollar amount members must pay for certain covered services. It is generally paid to a network provider at the time the service is rendered.

    The fixed dollar amount members must pay for certain covered services. It is generally paid to a network provider at the time the service is rendered.

    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    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.

    A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

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