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  • Claims > Submitting Claims for Non-Credentialed Practitioner in a Group Arrangement or for a Non-Credentialed Substitute Practitioner

    All providers who are part of an EmblemHealth-contracted medical group – and individually credentialed providers who have a non-contracted provider as part of their group and share a TIN, NPI, specialty/taxonomy code – are considered contracted providers for the purposes of claim payments and are considered “Substitute Practitioners”. Claims for Substitute Practitioner services should be billed by the medical group or by the regular participating practitioner and will be reimbursed at the regular participating practitioner’s contracted fee schedule.

    Substitute Practitioners are not required to enroll with the health plan and should not bill the health plan directly.

    Please note the following to ensure your claims for the Substitute Practitioner’s services are documented correctly:

    • Claims that include services provided by a Substitute Practitioner or must include the credentialed provider’s billing name, address and national provider identifier (NPI) in Block 33 of the claim form.
    • The name and mailing address of the Substitute Practitioner must be documented in Block 19, not Block 33.
    • When billing for a service provided by a Substitute Practitioner physician, the modifier Q5 or Q6 must follow the procedure code in Block 24D for services provided by the Substitute Practitioner.

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    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.

    An application for payment of benefits under a health care plan.

    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 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.

    The address designated by the member for all correspondence.

    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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