Claims > Claims Processing and Payment
Clean non-Medicare claims submitted electronically will be processed within 30 days; paper or facsimile clean non-Medicare claims will be processed within 45 days in accordance with the New York State law for prompt payment of claims. All claims submissions must include the TIN and NPI of the rendering and billing provider(s).
For all Medicare claims, EmblemHealth adheres to the Centers for Medicare & Medicaid Services (CMS) rules and regulations for prompt claims payment. That is, 95 percent of clean claims will be processed within 30 days, and all other claims will be processed within 60 days. For clean claims that are not processed within 30 days, interest will be paid at the prevailing rate under Medicare regulations.
EmblemHealth will not reimburse any claim submitted more than 365 days after the service date. Providers who wish to contest a claim that was denied for untimely filing should follow the provider grievance process set out in the applicable Dispute Resolution chapters for Commercial, Medicaid or Medicare. The reimbursement paid on late claims submissions may be reduced by an amount up to 25 percent. Participating practitioners may not bill the patient for services that EmblemHealth has denied because of late claims submission.
Duplicate claims should not be submitted. Providers may check the status of a prior claim submission by going to the EmblemHealth website, www.emblemhealth.com/providers, or calling a Provider Customer Care Advocate.
Claims that include a substitute physician should be submitted by the regular EmblemHealth-contracted practitioner, as substitute physicians are not required to enroll with the health plan and should not bill the health plan directly. See the Submitting Claims for Non-Credentialed Practitioner in a Group Arrangement or for a Non-Par Substitute Practitioner section later for more information on how to submit claims for substitute/non-contracted physicians at a contracted medical group service location.
Glossary terms found on this page:
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 legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.
A request to change an adverse determination that was based on administrative policies, procedures or guidelines.
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.
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.
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
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- 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.