EmblemHealth is reviewing out-of-network medical claims that were processed during the period from July 16, 2015, to Sept. 30, 2023, as the result of an agreement with the U.S. Department of Labor.
Participants, such as yourself, may have been responsible for payments to out-of-network providers that should have been covered by your EmblemHealth insurance plan if your plan is offered by a private employer. Specifically, as part of EmblemHealth’s agreement with the U.S. Department of Labor, you are entitled to reimbursement from EmblemHealth for any amount that your provider charged you as a result of EmblemHealth withholding payment to your provider because EmblemHealth previously overpaid your provider for a claim not related to you or your beneficiaries. If EmblemHealth withheld payment to your provider for this reason, it would be reflected on any Explanations of Benefits (EOBs) with the code “860 ADJUST/VOID CLAIM-ABNORMAL- EFFECTS 1099 AMT & NOT REMITS.”
If you incurred out-of-pocket costs related to out-of-network medical services during the above-referenced period resulting from the practice described above, please contact EmblemHealth at 800-624-2414 (TTY: 711) or download a form you can mail to us. You will need to include documentation. Examples of out-of-pocket costs may include:
- Paying a bill from a medical provider (including paying interest, fees, or penalties for late payment).
- Paying a collection agency hired by a provider (including interest, fees, or penalties).
- Having your wages garnished or a lien imposed because of an unpaid medical bill.
- Defending a legal proceeding regarding an unpaid medical bill; and/or
- Declaring bankruptcy because of a medical bill.
Keep in mind that the out-of-pocket costs referred to above must be costs that you incurred because your provider billed you as a result of EmblemHealth withholding payment to your provider due to a previous overpayment it paid to your provider. They may not be costs for any other reason, including cost-sharing like copays, coinsurance, and deductibles required under your plan.
Additionally, if you are still being billed by a medical provider or hospital or pursued by a collection agency because of a previous overpayment by EmblemHealth to your provider, please contact EmblemHealth at 800-624-2414 (TTY: 711). We will make our best efforts to try to resolve the outstanding bill or collections.
You have until 365 days from Dec. 15, 2023 to contact us about this issue, but we would prefer to hear from you as soon as possible. If you do not contact us within that time, any right to review by EmblemHealth that you may have under this letter will be considered waived.
Please keep in mind that the settlement with the U.S. Department of Labor does not change participants’ responsibilities for other copays and coinsurance requirements required under their EmblemHealth plan, including that participants may be responsible for a significant share of out-of-network claims or services that are not covered by their plan. If your medical bills result from other cost-sharing provisions of your plan rather than previous alleged overpayments to your provider, you would not be eligible for reimbursement by EmblemHealth as set forth in this letter.