Claims Corner — Get Your Claims Paid Quickly and Accurately

EmblemHealth understands that getting your claims paid quickly and accurately matters to you. That's why we created Claims Corner — a resource where you will find updated information on claims policy, best practices for coding your claims, changes to regulatory-driven payment methodology and other useful claims-related tips.

If you use a billing agent, please notify your representative of any relevant changes.

If you have any claims-related questions, please sign in to our secure Web site and use the Message Center.

LATEST UPDATES (All Sections)

Submit Claims with Accurate Pay To Information	(Submissions)	3/25/13
New HIP Outpatient Imaging Self-Referral Payment Policy	(Policy)	1/25/13
Unlisted Procedure Code Form	(Coding)	1/9/13
Change to In-Office Lab List for Pediatricians in HIP, EmblemHealth CompreHealth EPO/HMO and Vytra Networks	(Coding)	12/11/12
HIP and Vytra Dual Specialty Providers: Include Taxonomy Code on Claims	(Coding)	12/3/12
Look Back Periods to Reconcile Overpayments	(Policy)	11/22/12
Vaccines for Children Program: Revised Fee Schedule	(Coding)	10/10/12
Medicare National Coverage Determinations for Preventive Services	(Benefits)	9/05/12

CODING

The proper coding of procedure and diagnosis for billing purposes.

Unlisted Procedure Code Form	1/9/13
Change to In-Office Lab List for Pediatricians in HIP, EmblemHealth CompreHealth EPO/HMO and Vytra Networks	12/11/12
HIP and Vytra Dual Specialty Providers: Include Taxonomy Code on Claims	12/3/12
Vaccines for Children Program: Revised Fee Schedule	10/10/12
Shingles Vaccination Covered Under Medicare Part D	7/18/12
CPT 2012 Codes for Molecular Diagnostics	6/19/12
EmblemHealth Does Not Reimburse for PQRS Codes	5/22/12
Category II CPT Codes	5/22/12
EmblemHealth 5010 HIPAA transaction Standard Companion Guides	5/22/12
HCPCS S2900 (Robotic-assisted Surgery)	11/29/11
Assistant Surgeon Reimbursement Policy

SUBMISSIONS

Information on how to properly submit claims to us.

Submit Claims with Accurate Pay To Information	3/25/13
Submitting Electronic Claims With Member ID Numbers	7/17/12
EmblemHealth Consolidates Post Office Boxes for GHI HMO and EmblemHealth Medicare PPO	6/19/12
Billing for Noncovered Services	6/6/12
Submit Claims to New HealthCare Partners Address	1/18/12

BENEFITS

Information on changes to plan benefits that may have an impact on your claims.

Medicare National Coverage Determinations for Preventive Services	9/05/12
HPV Vaccine Covered for Girls and Boys	9/22/11
Revised Copayment Schedule for HIP Prime POS City of New York Benefit Plans	6/24/11
Buprenorphine Treatment by Authorized Practitioners Is a Covered Benefit

FEE SCHEDULE

Information and plan updates affecting your claims payments.

Consult Codes Removed From Fee Schedule Effective November 1, 2010	2/13/12
Fair Health Replaces HIAA/Ingenix in 2011	2/07/11
Changes to the In-Office Testing List for CompreHealth, HIP and Vytra Plans	10/28/10

POLICY

New or updated policy information relating to claims payment.

New HIP Outpatient Imaging Self-Referral Payment Policy	1/25/13
Look Back Periods to Reconcile Overpayments	11/22/12
Changes to the In-Office Testing List for CompreHealth, HIP and Vytra Plans	10/28/10
Coverage Denied for Never Events	8/19/10
Reminder GHI HMO DME Policy

UTILIZATION REVIEW

How utilization management may affect claims payment.

Palladian to Perform Retrospective Utilization Reviews for Outpatient Physical and Occupational Therapy	12/08/10
EmblemHealth Partners with OrthoNet	11/12/09

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