Timely Filing Requirements

07/26/2021

EmblemHealth would like to remind providers of our timely filing requirements for claims submissions:
 

Participating Providers:

  • Claims must be received within 120 days, post-date-of-service unless otherwise specified by the applicable participation agreement.
  • Claims where EmblemHealth is the secondary payer must be received within 120 days from the primary carrier’s EOB voucher date unless otherwise specified by the applicable participation agreement.
  • Corrected claims must also be submitted within 120 days, post-date-of-service unless otherwise specified by the applicable participation agreement.

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.

Providers who wish to appeal a claim denied for late submission should follow the provider grievance process in the Provider Manual Dispute Resolution chapters for the applicable 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.


For more information, see Claims | EmblemHealth (Chapter 30, under Timely Submission) and Claims Submission - Timely Filing | EmblemHealth.

Provider Update