Claims Submission Changes

Claims Submission Changes (EmblemHealth Provider Updates)

Claims submission changes listed in the blog refer to some new demands for providers sending HIPAA claims to EmblemHealth. Starting October 1, 2018, eviCore began to process claims for radiology services performed by radiologists for ACPNY members. Claims sent to EmblemHealth after October 1, 2018 will be denied, indicating that the claim should be sent to eviCore:

  • by electronic submission using Payor Number 14182
  • by mail: eviCore, 400 Buckwalter Place Blvd., Bluffton, SC 29910

Other specialties that provide radiology services can continue to submit their claims to EmblemHealth.

Timely Filing

For claims received on or after April 1, 2019, EmblemHealth will apply the timely filing provision found in each Participation Agreement with HIP Network Services IPA, Health Insurance Plan of Greater New York and HIP Insurance Company of New York for HIP members. The timely filing provision is 120 days unless the participation agreement states an alternative time frame to be applied.

Do Not Balance Bill Dual-Eligible Members

State regulation states that a health care professional or facility that provides Medicare Part A or Part B services cannot collect any deductible, coinsurance or copay amounts from Medicare/Medicaid dually-eligible individuals (State Regulation 18 NYCRR Section 360-7.7). Medicare and Medicaid payment, if any, must generally be accepted as payment in full.

If you provide health care services for EmblemHealth Medicare Advantage members that are dually-eligible, you must:

  • Bill the Managing Entity as primary payer.
  • Bill the state Medicaid plan as secondary payer.
  • Accept the Medicaid payment as payment in full.
  • Avoid collecting any cost-share from the member if he/she participates with their state Medicaid program.
  • Notify the member, prior to giving care, if you do not accept the state Medicaid as payment in full.

New Claims Submission Address for Behavioral Health

Effective immediately, there is a new mailing address for claims submissions to Beacon Health Options. The Latham, N.Y. address is no longer valid for claims submissions. The new address is: Beacon Health Options, P.O. Box 1850, Hicksville, N.Y. 11802-1850.

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