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  • Claims > Timely Submission

    Appropriate Timely Submissions When GHI Is Primary Carrier:

    • In-network claims: 365 days from date of service
    • Out-of-network claims: 18 months from date of service

      Appropriate Timely Submissions When GHI Is Secondary Carrier:

      • 365 days from the primary carrier’s EOB voucher date.

      EmblemHealth will apply the timely filing provisions found in each Participation Agreement with HIP Network Services IPA, Health Insurance Plan of Greater New York and HIP Insurance Company of New York for HIP members.

        Appropriate Timely Submissions When HIP Is Primary Carrier: 

        • For claims received on or after April 1, 2019, 120 days unless the participation agreement states an alternative time frame to be applied.
        • For claims received prior to April 1, 2019:
          • In-network claims: 365 days from date of service
          • Out-of-network claims: 365 days from date of service

          Appropriate Timely Submissions When HIP Is Secondary Carrier:

          • For claims received on or after April 1, 2019: 120 days from the primary carrier’s EOB voucher date unless the participation agreement states an alternative time frame to be applied.
          • For claims received prior to April 1, 2019: 365 days from the primary carrier’s EOB voucher date.

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          Glossary terms found on this page:

          An insurance company that either administers insurance or self-insures.

          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 date on which a service was rendered.

          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 use of providers who participate in the health plan's provider network. Many benefit plans encourage enrollees to use network providers to reduce the enrollee's out-of-pocket expense.

          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.

          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.

          The use of health care providers who have not contracted with the health plan to provide services. Depending on the member's contract, out-of-network services may not be covered.

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