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  • Claims > Billing the Member or Secondary Payor

    Network providers, in agreeing to accept EmblemHealth's reimbursement schedule for services rendered, shall not bill or seek payment from the member for any additional expenses (except for applicable copayments, co-insurance or permitted deductibles) including, but not limited to:

    • The difference between the charge amount and the EmblemHealth fee schedule or the difference between the member's copay amount and fee schedule if the copay amount is greater than the fee schedule.
    • Reimbursement for any claim denied for late submission, inaccurate coding, unauthorized service or as deemed not medically necessary.
    • Reimbursement for any claim pending review.

    Any provider attempting to collect such payment from the member does so in breach of the contractual provisions between the provider and EmblemHealth.

    The provider is responsible for collecting members' copayments at the time of service not to exceed the fee schedule amount. Copayments may not be charge for preventive care services as indicated in the  Your Plan Members chapter.

    Because member liability is determined after a claim is processed, the EOB will clearly state the member's payment responsibility. If any coinsurance or deductible remains, you can then bill your patient directly for the balance.

    EmblemHealth is not responsible for payment of noncovered services. Before rendering a noncovered service, the network provider must notify the member in writing that the service is not covered by our plan, notify the member of the cost of the service and receive the member's written consent to receive such service. Only then may the provider collect payment for the noncovered service(s) directly from the members.

    The member may sign an agreement with a provider whereby the member accepts responsibility for payment for noncovered services only.

    Medicare Dual Eligible Members

    Individuals with both Medicare and Medicaid coverage are called "dual eligibles." Depending on their category of Medicaid coverage, a dual eligible may receive state Medicaid plan assistance to cover their Medicare Part B premium, Medicare Parts A and B cost-share and certain benefits not covered by Medicare.

    Centers for Medicare & Medicaid Services (CMS) guidelines stipulate that dual eligibles who qualify to have their Medicare parts A and B cost-share covered by their state Medicaid plan are not responsible for paying their Medicare Advantage plan cost-shares for covered services. Providers may not balance bill for these amounts.

    To comply with this CMS requirement, providers treating dual eligibles enrolled in an EmblemHealth Medicare Advantage plan must do the following for these members:

    • Bill the Managing Entity as primary payor and the state Medicaid plan as secondary payor
    • Accept the Medicaid payment as payment in full and not collect any cost-share from the member if they participate with their state Medicaid program
    • Prior to providing services, notify the member if they do not accept the state Medicaid as payment in full

    Effective January 1, 2016, Medicaid will no longer reimburse partial Medicare Part B coinsurance amounts when the Medicare payment exceeds the Medicaid fee or rate for that service. If the Medicare payment is greater than the Medicaid fee, no additional Medicaid payment will be made.

    Effective July 1, 2016, Medicaid will no longer pay the full copayment or coinsurance amounts for Medicare Part C claims. Medicaid will reimburse at the rate of 85 percent of the Medicare Part C copayment or coinsurance amount.

    These changes also apply to pharmacy claims for medications and supplies. There is no change to the current reimbursement methodology of Medicare Part B coinsurance or Part C copayment/coinsurance for ambulance providers, psychologists, or Federally Qualified Health Centers (FQHCs). These providers will continue to be paid the full Medicare Part B coinsurance and Part C copayment/coinsurance amounts.

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    Glossary terms found on this page:

    Services that have been approved for payment based on a review of EmblemHealth's policies.

    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.

    The government agency responsible for administering the Medicare and Medicaid programs.

    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.

    A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

    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.

    A medically necessary service for which a member is entitled to receive partial or complete coverage under the terms and conditions of the benefit program, is within the scope of the practitioner's practice and the practitioner is authorized to render pursuant to the terms of the agreement.

    A portion of eligible expenses that an individual or family must pay during a calendar year before EmblemHealth will begin to pay benefits for covered services.

    A form sent to the enrollee after a claim for payment has been processed by the health plan. The form explains the action taken on that claim. This explanation usually includes the amount paid, the benefits available, reasons for denying payment and the claims appeal process. Also called Explanation of Benefits.

    The fee determined by the insurer to be acceptable for a procedure or service that the physician agrees to accept as payment in full.

    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.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    Health care that is rendered by a hospital or a licensed or certified provider and is determined by EmblemHealth to meet all of the criteria listed below:

    • It is provided for the diagnosis or direct care or treatment of the condition, illness, disease, injury or ailment.
    • It is consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment.
    • It is in accordance with accepted standards of good medical practice in the community.
    • It is furnished in a setting commensurate with the member's medical needs and condition.
    • It cannot be omitted under the standards referenced above.
    • It is not in excess of the care indicated by generally accepted standards of good medical practice in the community.
    • It is not furnished primarily for the convenience of the member, the member's family or the provider.
    • In the case of a hospitalization, the care cannot be rendered safely or adequately on an outpatient basis or in a less intensive treatment setting and, therefore, requires the member receive acute care as a bed patient.

    The fact that a provider has prescribed a service or supplies care does not automatically mean the service or supply will qualify for reimbursement under the EmblemHealth plan. To be eligible for reimbursement by EmblemHealth, all covered services must meet EmblemHealth's medical necessity criteria, described above.

    Medically necessary with respect to Medicaid and Family Health Plus members means health care and services that are necessary to prevent, diagnose, manage or treat conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person's capacity for normal activity or threaten some significant handicap.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    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. Also known as MA.

    This part of Medicare provides medical surgical benefits for Medicare beneficiaries for a modest premium.

    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.

    The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

    A physician, hospital or other provider who has signed an agreement to covered services to EmblemHealth plan members. A network provider is a member of the EmblemHealth network of network providers applicable to the member's certificate. Therefore, they are sometimes referred to as participating providers. Payment is made directly to a network provider. Please consult the EmblemHealth Directory or go online to search for network providers.

    A prepaid payment or series of payments made to a health plan by purchasers and often plan members for health insurance coverage.

    Comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, and generally including routine physical examinations and immunization.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.


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