Claims Submission - Timely Filing

Review Dates: 09/04/2024; 08/18/2023; 06/12/2024;

Date Issued: 03/09/2023;

Participating Medical, Facility, and Hospital Providers

Unless otherwise specified by the applicable participation agreement or the member’s self-funded plan’s provisions, new claims must be received within 120 days of the:

• Date-of-service.
• Primary carrier’s explanation of payment (EOP) issue date when EmblemHealth is the secondary payer.

Self-funded groups (also called administrative service organization clients or “ASO clients”) may set their own claim filing limits. These supersede any other contracted or published filing limits. The number of days begins with the date-of-service or primary carrier’s EOP. 

Non-Participating Providers

Claims must be received within the following time frames after the date-of-service or primary carrier’s explanation of payment (EOP) issue date when EmblemHealth is the secondary payer:

• Commercial: 18 months, except for members affiliated with self-funded groups that have set their own limits as shown in the following table:

• Medicaid, and Child Health Plus (CHPlus): 15 months.
• Medicare: 365 days.

Behavioral Health Providers

Behavioral health providers should reference the Carelon Behavioral Health Provider Handbook for applicable timely filing limits.

Dental Providers

Dental providers should reference the Office Manager’s Handbook section 3.1 for applicable timely filing limits.

Appealing Claims Denied for Late Submission

Providers who wish to appeal a claim denied for late submission should follow the provider grievance process in the Dispute Resolution chapters for the line of business: 

• Commercial/CHPlus.
• Medicaid.
• Medicare.

Reimbursement may be reduced by up to 25% for timely filing claims denials that are overturned upon successful appeal. Participating practitioners may not bill the patient for services that EmblemHealth has denied because of late submission.

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