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  • Claims > Electronic Claims Submission

    Today, thousands of health care practitioners have eliminated paper claims and are submitting electronic claims to EmblemHealth in HIPAA-compliant professional provider (837P), institutional provider (837I) and dental provider (837D) EDI claims transaction formats.

    Helpful Tips For Proper Setup of Electronic Billing Systems

    • When billing electronically, please allow a reasonable amount of time to complete your account receivable reconciliation process. Ensure that your billing system is not set up to automatically re-bill every 30 days.
    • Many times the payment for the original claim was applied to the copay or the service was denied for medical necessity, eligibility or another reason. Please make sure that your automated billing system accurately posts patient responsibility data and claims settlement messages.
    • Ensure that your billing system does not automatically generate a paper claim. This duplicate billing practice is costly and delays processing.

      Some Advantages of Electronic Claim Submission

      • Quicker claims submission, which means faster reimbursement to you
      • No paper claims to stock and complete
      • Simplified record keeping by eliminating lost claims paperwork
      • Reduced clerical time and the costs to process and mail paper claims

        Pathways For Electronic Claim Submission To EmblemHealth

        Providers, both institutional and professional, may use practice management system vendors, billing services or clearinghouses to submit claims and other EDI transactions to EmblemHealth.

        Note: Practice management system vendors and billing services offer a variety of EDI solutions to the health care community and charge fees and/or transaction costs for their services. EmblemHealth does not specifically recommend or endorse any vendor or billing service.

        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).

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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

        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 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 determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

        A federal act that protects people who change jobs, are self-employed or have pre-existing medical conditions. The act standardizes an approach to the continuation of health care benefits for individuals and members of small group health plans and establishes parity between the benefits extended to these individuals and those offered to employees in large group plans. The act also contains provisions to ensure that prospective or current enrollees in a group health plan are not discriminated against based on health status and protects the confidentiality of protected health information of members. Also known as the Health Insurance Portability and Accountability Act.

        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 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 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.

        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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