Duplicate Claims from a Non-Physician Practitioner

Date Issued: 5/3/2019

EmblemHealth has been implementing payment policies that reflect guidelines set forth by industry authorities. Our goal is to process claims consistently and in accordance with best practice standards.

EmblemHealth has instituted additional payment policies for duplicate claims policy as it relates to Non-Physician Practitioner (NPP) with the same tax ID and the primary diagnosis on the submitted claims when it matches any diagnosis (first three characters) on a different claim regardless of Provider ID and specialty.

A duplicate claim is defined as any claim submitted by a physician or provider for the same service provided to a particular individual on a specified date of service that was included in a previously submitted claim. EmblemHealth compares new claims and claim lines received against other claims and claim lines in both history and in the same new claim batch.

As always, we appreciate your participation in our network, and the quality care you provide to our members. If you have any questions, please contact your EmblemHealth Network Manager.