Network providers are required to accept EmblemHealth’s reimbursement schedule for services rendered. Network providers must not bill or seek payment from the member for any additional expenses (except for applicable copayments, coinsurance, or permitted deductibles) including, but not limited to:
- The difference between the charge amount and the EmblemHealth fee schedule, or the difference between the member’s copay amount and fee schedule if the copay amount is greater than the fee schedule.
- Reimbursement for any claim denied for late submission, inaccurate coding or unauthorized service, or deemed not medically necessary.
- Reimbursement for any claim pending review.
Any provider attempting to collect such payment from the member has breached their obligations under their contract with EmblemHealth.
The provider is responsible for collecting members’ copayments at the time of service (not to exceed the fee schedule amount). Copayments may not be charged for preventive care services as indicated in the Member Policies and Rights chapter.
A member’s out-of-pocket payment responsibility is shown on the Explanation of Benefits (EOB) sent to the member and the Explanation of Payment (EOP) or 835 transaction for an electronic remittance advice (remit) sent to the provider. (See How do I receive payment, sign up for EFT/ERA and find my EOPs/Remits and 835/ERAs? for instructions for finding EOPs and 835/Remits online.) If any coinsurance or deductible remains, you can then bill your patient directly for the balance.
EmblemHealth is not responsible for payment of noncovered services. Before delivering a noncovered service, the network provider must notify the member in writing that the service is not covered by our plan, notify the member of the cost of the service, and receive the member’s written consent to receive the service. Only then may the provider collect payment for the noncovered service(s) directly from the member.
The member may sign an agreement with a provider in which the member accepts responsibility for payment for noncovered services only.
To determine Medicare member liability for services typically not covered, but could be covered under specific conditions, the member, or the provider acting on behalf of the member, must request a preauthorization organization determination. If EmblemHealth denies the service, we will issue a standardized denial notice with appeal rights. Only then may the provider collect payment for the noncovered service(s) directly from the Medicare member. An organization determination is not required to collect payment from a member where the Evidence of Coverage (EOC) or other related material is clear that a service or item is not covered.
Medicare Dual Eligible Members
Individuals with both Medicare and Medicaid coverage are called “dual-eligibles.” Depending on their category of Medicaid coverage, a dual eligible may receive Medicaid plan assistance to cover their Medicare Part B premium, Medicare Parts A and B cost-share, and certain benefits not covered by Medicare.
Centers for Medicare & Medicaid Services (CMS) guidelines stipulate dual-eligibles who qualify to have their Medicare Parts A and B cost-share covered by their state Medicaid plan are not responsible for paying their Medicare Advantage plan cost-shares for covered services. Providers may not balance bill for these amounts.
To comply with this CMS requirement, providers treating dual-eligibles enrolled in an EmblemHealth Medicare Advantage plan must do the following for these members:
- Bill the Managing Entity as the primary payor, and the state Medicaid plan as the secondary payor.
- Accept the Medicaid payment as payment in full and not collect any cost-share from the member if the provider participates with their state Medicaid program.
- Prior to providing services, notify the member if they do not accept the state Medicaid payment in full.
For more information, visit the CMS website.
New York State (NYS) Medicaid does not reimburse partial Medicare Part B coinsurance amounts when the Medicare payment exceeds the Medicaid fee or rate for a service. If the Medicare payment is greater than the Medicaid fee, no additional Medicaid payment is made.
NYS Medicaid does not pay the full copayment or coinsurance amounts for Medicare Part C claims. Medicaid reimburses at the rate of 85% of the Medicare Part C copayment or coinsurance amount.
This also applies to pharmacy claims for medications and supplies but does not apply to Medicare Part B coinsurance or Part C copayment/coinsurance for ambulance providers, psychologists, or Federally Qualified Health Centers (FQHCs). These providers are paid the full Medicare Part B coinsurance and Part C copayment/coinsurance amounts.
As of Jan. 1, 2020, EmblemHealth no longer pays the full cost of Part B drugs. Please bill New York State Medicaid for our dual eligible members’ cost-share.