Tag: #deniedclaims

Posted in EmblemHealth NY, NY Providers, Payer Updates

Emblem Health:  claims timely filling update- Self Funded Plans (ASO)

Posted on by KR2Medical Billing

Keeping up current on any claim timely filing updates is crucial for your business!

Claims that are denied for timely filing can be rarely appealed and get paid. (Certain situations like COB/Natural disaster)

So, I always pay a close attention to any timely filling changes that are reported by the healthcare payers/plans.

Below please note the changes that took place for Self Funded (ASO) type of plans.

Via Emblem Health

Find this type of information useful? Please follow my blog for more healthcare related information.

  • Tufts Health One Care: New Plan name and ID cards
    Does your provider accept Tufts Health One Care insurance? Then this blog post is for you- don’t leave money on the table and waste precious administrative time! As of Jan 1,2026- Tufts Health One Care became Tufts D-SNP – with such change members will receive new ID cards and member numbers. New ID cards: Authorizations… Read more: Tufts Health One Care: New Plan name and ID cards
  • Fidelis MMC: healthy nutrition benefit
    Fidelis (NY) has partnered up with Foodsmart vendor to offer the Managed Medicaid Members nutrition services- “fully covered by the plan”. The services include a personalized telenutrition from registered nutritionist. Foodsmart services include: For more information, providers should contact: Paula West, Director of Provider Relations, at Paula.West@foodsmart.com. Ready to refer a member? Find this information… Read more: Fidelis MMC: healthy nutrition benefit
  • UHC Medicaid: Idaho: diabetic DME coverage change-benefit
    Starting for DOS 4/1/26 and thereafter the following codes will be covered through the patient pharmacy benefit and no longer will be covered under patient medical benefit. For DOS 1/1/26 through 3/1/26- providers can still bill either through medical benefit or pharmacy benefit. Find this type of content useful? Follow my blog!
  • Anthem BCBS: 32BJ fund new TPA and cards
    As the new year starts so do the change of theember ID changes and or group numbers. Is your provider office aware of these changes? Please note that for any 32BJ members there is a new TPA, group#, member ID, and cards. Please note the new ID: Effective Jan 1,2026- new members ID prefix BJVBJ.… Read more: Anthem BCBS: 32BJ fund new TPA and cards
  • Are you leaving revenue on the table?
    Aetna update! Is your practice compliant? Are you appending proper modifiers to radiology, diagnostic services and surgery services- when billed with the following ICD-10 codes: Z53.01, Z53.09, Z53.1, Z53.20, Z53.21, Z53.29, Z53.8, Z53.9? As per Aetna- if the following modifiers are not billed on the claims for the above services with above named ICD-10 codes-… Read more: Are you leaving revenue on the table?
Posted in Insurance

Announcement: NY Empire Plan Claim Submission for 2019 Services -April 29,2020

Posted on by KR2Medical Billing

General: Please remember that UnitedHealthCare (claim administrator for NY Empire Plan) has a claim submission policy  of 120 days from the DOS (Date of Service). Empire Plan Secondary Claims also have a claim submission policy of 120 days from the date that Medicare or another insurance claim has processed the claim.

For Services performed  at the end of year 2019 have to be submitted on April 29,2020

Paper Claims Address: those providers that are unable to submit electronic claims have to send their claims to The Empire Plan, PO Box 1600, Kingston, NY 12402-1600

Reminder: When benefits are denied because of the claim being submitted late, the participating physician or health care professional MAY NOT BILL the patient for the charges on that claim.

Posted in Insurance, My services, Payers and CPT reinbursement, Training

Empire Plan(UHC) and CPT code 95004

Posted on by KR2Medical Billing

This is a third installment in my Payers and CPT codes series.

In this installment we will look at the payer Empire Plan (Light Blue card). For this payer UHC is the third party administrator and handles all administrative duties.

Now I am sure you know that when you see a patient with this type of insurance, there is a $20 copay for the office visit. However, not many providers know that there is also another fee for another service, if that services is performed on the same date.

The following will help you to collect the correct amount of patient responsibility from the patient, on the day of services are rendered, and not wait until the claim is processed, which could be 14 or more days; thus increasing your cash flow and reduce your outstanding A/Rs.

In this scenario, you have a new patient coming in to see an allergist for an unspecified allergic reaction:

Code 1: 99204 or 99203 – NEW PATIENT Patient responsibility- $20

Simple.

Ok, now the patient also has not taken any antihistamines in at least the last week and would like to do prick allergy testing , cpt code 2: 95004.

According to UHC, the third party administrator for this plan, 95004- is considered a separate (diagnostice) procedure if performed on the same day, therefore there is also an additional co payment of $20 that is attributed to the patient responsibility.

So, lets review- new patient code 99204 or 99203 w/25 ,a code 95004 for skin testing – patient copay $20 for the office visit and $20 for the prick allergy testing.

Since I already know this in advance, I have a separate form that I give to patients when they arrive to the office, BEFORE performing the procedure.

Giving the patients the option of either doing the prick testing or sending them for blood work (no additional fee when they on that day, if dont in the outside lab)

If you have any other further questions, please feel free to contact me via email or phone, listed on my about me page, or via my LINKEDIN account or my Facebook page.

Until next time!