Submitting Claims for Non Credentialed Practitioner in a Group Arrangement

Date Issued: 5/24/2016

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.