HIPAA Claims

HIPAA Claims EmblemHealth: Look Back Periods To Reconcile Overpayments To ensure fair and accurate HIPAA claims payment, EmblemHealth conducts audits of previously adjudicated claims. The time period for these audits is referred to as the “Look Back Period.” HIPAA claims may be audited based on the settlement or paid/check date, not the date(s) of service. The date Read More →

Medicare Dual Eligible Members

Medicare Dual Eligible Members (EmblemHealth Billing Guides) Medicare Dual Eligible Members are individuals with both Medicare and Medicaid coverage. Depending on their category of Medicaid coverage, a dual eligible may receive state Medicaid plan assistance to cover their Medicare Part B premium, Medicare Parts A and B cost-share and certain benefits not covered by Medicare. Read More →

Billing the Member

Billing the Member or Secondary Payor (EmblemHealth Billing Requirements) 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 Read More →

EmblemHealth Claims Processing

EmblemHealth Claims Processing and Payment Guidelines EmblemHealth 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 Read More →