Date Issued: 03/09/2023
Timely filing requirements for medical/hospital claim submissions*:
Participating Providers
Unless otherwise specified by the applicable participation agreement:
- Claims must be received within 120 days post-date-of-service.
- Claims where EmblemHealth is the secondary payer must be received within 120 days from the primary carrier’s explanation of payment (EOP) date.
- Corrected claims must also be submitted within 120 days post-date-of-service.
Non-Participating Providers
- Commercial products: claims must be received within 18 months, post-date-of-service.
- Medicaid, and Child Health Plus (CHPlus): claims must be received within 15 months, post-date-of-service.
- Medicare: claims must be received within 365 days, post-date-of-service.
For more information, visit the Claims Corner section of our Provider website, Providers | Claims Corner
If you need to speak with someone, call Provider Services at 866-447-9717. our hours are 8 a.m. to 6 p.m., Monday to Friday.
*Other claim types, such as dental and behavioral health, may have different claims timely filing requirements. Dental providers, may reference Clinical Corner – Dental and behavioral health providers may reference the Beacon Provider Handbook.
Reminders
Correct CPT Code Use
- Check the coding crosswalk to confirm that the codes you are submitting are compatible with each other before billing.
- Confirm that the age of the member matches with the diagnosis code billed on the claim.
- When billing a bilateral CPT code, verify that the code is inherently bilateral, meaning providers need not add any additional modifier. For codes where the LT/RT modifier is required, make certain to add the modifier in two different lines as two separate units or, as per the CMS guidelines, bill the CPT with the 50 modifier.
Provide Complete Medical Records and Correct Claim Form Information
- For coding denials, send the appropriate medical records for the claim to be reviewed.
- When indicated/appropriate, provide complete medical records to ensure the claim is not denied for additional information needed.
- Verify that the correct service location address is displayed in box #32 on the claim form.
No Split Billing
- Wait to bill all services rendered on the same day together.
