![]() ![]() 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.Network providers must not bill or seek payment from the member for any additional expenses (except for applicable copayments, coinsurance, or permitted deductibles) including, but not limited to: Network providers are required to accept EmblemHealth’s reimbursement schedule for services rendered. When billing for a service provided by a Substitute Practitioner physician, the modifier Q5 or Q6 must follow the procedure code in Block 24D for services provided by the Substitute Practitioner.The name and mailing address of the Substitute Practitioner must be documented in Block 19, not Block 33.Claims for services provided by a Substitute Practitioner must include the credentialed provider’s billing name, address, and NPI in Block 33 of the claim form.Note the following to ensure your claims for the Substitute Practitioner’s services are documented correctly: Substitute Practitioners are not required to enroll with the health plan and should not bill the health plan directly. Providers may check the status of a prior claim submission by signing in to /providers and using the Claim Search drop-down under the Claims tab, or calling a Provider Customer Service representative. You may read more about how to avoid duplicate claims submissions at Claims Corner on .Īll providers who are part of an EmblemHealth-contracted medical group – and individually credentialed providers who have a non-contracted provider as part of their group and share a TIN, NPI, or specialty/taxonomy code – are considered contracted providers for the purposes of claim payments and are considered “Substitute Practitioners.” Claims for Substitute Practitioner services should be billed by the medical group or by the regular participating practitioner and are reimbursed at the regular participating practitioner’s contracted fee schedule. Duplicate claims delay claims processing and create confusion for the member. ![]() For clean claims not processed within 30 days, interest is paid at the prevailing rate under Medicare regulations.ĭo not submit duplicate claims. All claim submissions must include the tax identification number (TIN), NPI, and applicable taxomomy of the rendering and billing provider(s).įor 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. Clean non-Medicare claims submitted electronically are processed within 30 days paper or facsimile clean non-Medicare claims are processed within 45 days in accordance with the New York State law for prompt payment of claims. ![]()
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