Participating practitioners may not bill the patient for services that EmblemHealth has denied because of late submission. Reimbursement may be reduced by up to 25% for timely filing claims denials that are overturned upon successful appeal. Providers who wish to appeal a claim denied for late submission should follow the provider grievance process in the Dispute Resolution chapters for the line of business: Medicaid, and Child Health Plus (CHPlus): 15 months.īehavioral health providers should reference the Carelon Behavioral Health Provider Handbook for applicable timely filing limits.ĭental providers should reference the Office Manager’s Handbook section 3.1 for applicable timely filing limits.Īppealing Claims Denied for Late Submission.Self-Funded Group Out-of-Network Timely Filing Limits For other language assistance or translation services, please call the customer service number for your local Blue Cross and Blue Shield company. Commercial: 18 months, except for members affiliated with self-funded groups that have set their own limits as shown in the following table:.Self-Funded Group In-Network Timely Filing LimitsĬlaims must be received within the following time frames after the date-of-service or primary carrier’s explanation of payment (EOP) issue date when EmblemHealth is the secondary payer: The number of days begins with the date-of-service or primary carrier’s EOP. These supersede any other contracted or published filing limits. Self-funded groups (also called administrative service organization clients or “ASO clients”) may set their own claim filing limits. Primary carrier’s explanation of payment (EOP) issue date when EmblemHealth is the secondary payer.Unless otherwise specified by the applicable participation agreement or the member’s self-funded plan’s provisions, new claims must be received within 120 days of the: Participating Medical, Facility, and Hospital Providers
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