Billing the Member or Secondary Payor (EmblemHealth Billing Requirements)

Billing the Member

Network providers, in agreeing to accept EmblemHealth’s Billing the Member and Secondary Payor requirements and reimbursement schedule for services rendered, shall not bill or seek payment from the member for any additional expenses (except for applicable copayments, co-insurance 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, unauthorized service or as deemed not medically necessary.
  • Reimbursement for any claim pending review.

Any provider attempting to collect such payment from the member does so in breach of the contractual provisions between the provider and 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 charge for preventive care services as indicated in the  Your Plan Members chapter.

Because member liability is determined after a claim is processed, the EOB will clearly state the member’s payment responsibility. 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 rendering 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 such service. Only then may the provider collect payment for the noncovered service(s) directly from the members. The member may sign an agreement with a provider whereby the member accepts responsibility for payment for noncovered services only.

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