EmblemHealth HIPAA Claims Guidelines
In order for provider partners to be paid correctly and quickly, EmblemHealth provides guidance on best practices for claims submissions, payments, and finding information on claims submitted to EmblemHealth for processing.
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.
Clean non-Medicare claims submitted electronically are processed within 30 days; paper or facsimile clean nonMedicare claims are processed within 45 days in accordance with the New York State law for prompt payment of claims. All claim submissions must include the tax identification number (TIN), NPI, and applicable taxomomy of the rendering and billing provider(s).
For all Medicare claims, EmblemHealth adheres to the Centers for Medicare & Medicaid Services (CMS) rules and regulations for prompt claims payment: 95% of clean claims are processed within 30 days, and all other claims are processed within 60 days. For clean claims not processed within 30 days, interest is paid at the prevailing rate under Medicare regulations.
Do not submit duplicate claims. Duplicate claims delay claims processing and create confusion for the member. Providers may check the status of a prior claim submission by signing in to emblemhealth.com/providers and using the Claim Search drop-down under the Claims tab, or calling a Provider Customer Service representative.
To learn more about HIPAA EDI and become a certified EDI Professional please visit our course schedule page.