Starting Dec. 11, 2025, EmblemHealth is expanding its dispute resolution processes. We will introduce a formalized workflow called a “Claim Dispute,” which may be submitted up to 180 days after the Explanation of Payment is issued. The new process will replace the initial claim inquiry workflow currently available prior to the submission of a Grievance.
EmblemHealth will offer providers the opportunity to dispute or question the outcome of a claim’s payment before submitting a formal grievance or appeal. A claim dispute should only be submitted for a paid claim, one applied to the patient’s deductible/copayment, or denied by the plan.
We will update the EmblemHealth Provider Manual to capture the new workflow and notify providers of the updates through the provider newsletter.