EmblemHealth Claims Processing and Payment Guidelines

EmblemHealth Claims ProcessingEmblemHealth Claims Processing (clean non-Medicare claims) will be done within 30 days; paper or facsimile clean non-Medicare claims will be processed within 45 days in accordance with the New York State law for prompt payment of claims. All claims submissions must include the TIN and NPI 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. That is, 95 percent of clean claims will be processed within 30 days, and all other claims will be processed within 60 days. For clean claims that are not processed within 30 days, interest will be paid at the prevailing rate under Medicare regulations.

EmblemHealth will not reimburse any claim submitted more than 365 days after the service date. Providers who wish to contest a claim that was denied for untimely filing should follow the provider grievance process set out in the applicable Dispute Resolution chapters for Commercial, Medicaid or Medicare. The reimbursement paid on late claims submissions may be reduced by an amount up to 25 percent. Participating practitioners may not bill the patient for services that EmblemHealth has denied because of late claims submission.

Duplicate claims should not be submitted. Providers may check the status of a prior EmblemHealth claim submission by going to the EmblemHealth website, www.emblemhealth.com/providers, or calling a Provider Customer Care Advocate.

EmblemHealth Claims that include a substitute physician should be submitted by the regular EmblemHealth-contracted practitioner, as substitute physicians are not required to enroll with the health plan and should not bill the health plan directly.

Electronic claims should be submitted to us by using the Payor IDs. Paper claims (CMS 1500 forms) may be sent to the addresses indicated, unless otherwise noted on the member’s ID card.

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