EmblemHealth Timely Filing Limit 2026: 120 Days, 220 for Corrected Claims, and Every Exception

The EmblemHealth timely filing limit is 120 days from the date of service (DOS) for participating medical, facility, and hospital providers. If EmblemHealth pays second, the 120 days run from the primary payer’s explanation of payment (EOP) date. A participation agreement or self-funded plan can set a different number.

Non-participating providers get 18 months for commercial claims, 15 months for Medicaid and Child Health Plus, and 365 days for Medicare. EmblemHealth adds 100 days to the original limit for corrected claims, so 120 days becomes 220 days from the date of service.

A timely filing limit (TFL) is the deadline for a payer to receive your claim. Online, you’ll see three EmblemHealth numbers: 120 days, 180 days, and 365 days. Each one is correct for a specific plan or contract. Load the wrong one into your billing system, and you’ll write off claims you could have saved.

EmblemHealth Timely Filing Limits at a Glance (2026)

Use this table to find the EmblemHealth timely filing limit for a specific claim: plan first, network status second, claim type third. Each row stands on its own, and the last column names the EmblemHealth document behind the number so you can check it yourself.

EmblemHealth timely filing limits by claim type, verified October 3, 2026

Source: EmblemHealth’s timely filing policy and the EmblemHealth or Carelon document named in each row.

Pick the most specific row that fits the member. A BCTGM Local 53 member follows the self-funded row, and a NYCE PPO member seen in 2026 follows the NYCE PPO row, even though EmblemHealth plays a role in both plans.

Protect these timely filing deadlines with a short gap between visit and claim. A practice that batches EmblemHealth claims once a week burns days it’ll need later for rejections and COB problems. MedSole’s daily claims submission team scrubs each claim against payer-specific edits and tracks it from transmission through acknowledgment.

Is the EmblemHealth Timely Filing Limit 120 or 180 Days?

EmblemHealth’s standard timely filing limit is 120 days. As of October 2026, the 180-day figure applies to two cases: NYCE PPO in-network claims and the BCTGM Local 53 self-funded group. A participating provider who uses 180 days on any other EmblemHealth claim misses the deadline by 60 days.

Where the 180-Day Number Comes From

Several billing company blogs updated in 2026 still give 180 days as the EmblemHealth timely filing limit for all claims. You can trace that number to two real rules. EmblemHealth lists 180 days for NYCE PPO in-network services on or after January 1, 2026, and BCTGM Local 53 has used 180 days since January 1, 2020.

In billing offices, EmblemHealth often goes by Emblem, and the Emblem timely filing limit to load in your practice management system is 120 days. Treat 180 days as a plan-specific exception, and keep it off the payer-level default.

Why Older Manuals Say 365 Days for GHI

An older EmblemHealth provider manual PDF lists 365 days for GHI in-network claims and 120 days for HIP claims received on or after April 1, 2019. EmblemHealth’s current Claims chapter skips both numbers and refers providers to the Claims Corner timely filing page, which lists 120 days.

Google’s AI Overview for this search still blends the two into “120 days to 365 days.” The GHI insurance timely filing limit for a participating provider is 120 days today. If a legacy GHI agreement in your files states 365 days, follow the agreement, since EmblemHealth applies 120 days “unless otherwise specified by the applicable participation agreement.”

Which EmblemHealth Plan Are You Billing? GHI, HIP, and NYCE PPO

GHI now operates as EmblemHealth Plan, Inc., and HIP Insurance Company of New York (HIPIC) is now EmblemHealth Insurance Company. Health Insurance Plan of Greater New York (HIP) remains an EmblemHealth company. Read the member’s ID card before you build the claim, because the company named on it sets the payer ID and mailing address.

GHI, HIP, and EmblemHealth: Same Company, Different Claim Routes

Yes, GHI and HIP are both part of EmblemHealth, according to EmblemHealth’s GHI and HIP notice dated April 16, 2025. The Emblem Health payer ID changes with the company on the card. HIP professional claims go to payer ID 55247, GHI claims to 13551, GHI-branded HMO claims to 25531, and Vytra-branded HMO claims to 22264.

Before you count 120 days, confirm you’re participating with that EmblemHealth company. You can check it with the Check Provider Network Status tool in EmblemHealth’s provider portal. If the tool shows you out of network for a company you thought you’d joined, fix the provider enrollment and credentialing gap before more claims age.

Line of business matters as much as the company. EmblemHealth covers commercial, Medicaid managed care, HARP, Child Health Plus, Essential Plan, and Medicare Advantage members, and its non-participating limits differ by line. ConnectiCare, also part of EmblemHealth, follows the same corrected claim policy.

Is EmblemHealth the Same as Cigna or UnitedHealthcare?

No. Cigna Healthcare and UnitedHealthcare are separate companies that work with EmblemHealth in specific programs. Through the EmblemHealth Bridge Program, some EmblemHealth members can see providers in the Cigna Healthcare PPO Network outside New York State. EmblemHealth’s own page calls Cigna an independent company with no affiliation.

UnitedHealthcare partners with EmblemHealth on NYCE PPO. Claims for NYCE PPO services on or after January 1, 2026 go to UMR under payer ID 26992. Keep each company’s limits in its own lane: Cigna members follow Cigna timely filing rules, and EmblemHealth members follow EmblemHealth’s.

The 120-Day Rule for Participating Providers

EmblemHealth must receive new claims from participating medical, facility, and hospital providers within 120 days of the date of service. The participation agreement or the member’s self-funded plan can set a different number, and that number wins.

When the 120-Day Clock Starts

EmblemHealth starts the 120-day clock on the date of service for a primary claim. For a secondary claim, the clock starts on the issue date printed on the primary carrier’s EOP. Your mail date and ERA posting date don’t move it.

Facility claims follow the same date-of-service rule on EmblemHealth’s timely filing page. Some facility contracts define the start as the discharge date, and if yours does, follow the contract instead of the page. EmblemHealth’s page doesn’t spell out a separate inpatient rule, so don’t assume one.

EmblemHealth Counts the Day It Receives the Claim

EmblemHealth counts the day it receives the claim, so a claim your clearinghouse rejected doesn’t count as filed. Save the 999 and 277CA acknowledgments for each batch. Those reports are your proof of timely filing if EmblemHealth later says a claim arrived after day 120.

After receipt, EmblemHealth processes clean non-Medicare claims within 30 days for electronic submissions and 45 days for paper ones. On Medicare plans, EmblemHealth processes 95% of clean claims within 30 days and the rest within 60. Treat the 120 days as your claim window and the processing time as EmblemHealth’s.

New York’s Prompt Pay Law Behind the 120 Days

New York Insurance Law 3224-a requires providers to submit claims within 120 days after the date of service, and it lets insurers agree to terms more favorable to the provider. Medicaid and Child Health Plus contracts can set a different window, with a floor of 90 days. EmblemHealth’s 120-day rule matches the state default.

Section 3224-a’s payment clock gives insurers 30 days for undisputed electronic claims and 45 for paper. In most cases, self-funded plans sit outside state insurance law, so EmblemHealth’s ASO groups can set their own limits. The NYCE PPO provider FAQ says New York’s prompt pay laws don’t apply to that plan.

How to Calculate Your EmblemHealth Deadline

Work out the EmblemHealth timely filing limit for each claim in three steps, and write the deadline on the claim record before it goes out:

1. Find the start date: the date of service, or the primary EOP issue date for a secondary claim.
2. Count 120 calendar days, starting with the day after the start date. Weekends and holidays count.
3. Set an internal submission target of 30 days or fewer, which leaves 90 days for rejections and fixes.

EmblemHealth doesn’t publish a weekend rollover, so don’t assume one. If day 120 lands on a Sunday, treat the Friday before it as your last safe day.

2026 timely filing calendar for EmblemHealth participating providers

Non-Participating Provider Deadlines: 18 Months, 15 Months, or 365 Days

EmblemHealth gives non-participating providers 18 months for commercial claims, 15 months for Medicaid and Child Health Plus claims, and 365 days for Medicare claims, counted from the date of service or the primary payer’s EOP date.

• Commercial plans: 18 months, unless a self-funded group sets a shorter limit
• Medicaid managed care and Child Health Plus: 15 months
• Medicare Advantage: 365 days, under EmblemHealth’s own plan rules

Read the line of business on the ID card before you count. A self-funded group can shorten the 18 months, and BCTGM Local 53 does: its out-of-network limit is 180 days. Check the self-funded table below before you trust 18 months on a commercial claim.

EmblemHealth’s 365 days for Medicare claims is the plan’s own rule for its Medicare Advantage members. Original Medicare runs on a separate 12-month clock, explained in our Medicare timely filing limit guide. Keep the two apart when a patient switches plans.

The 15-month Medicaid TFL here covers EmblemHealth’s Medicaid managed care members. New York Medicaid fee-for-service claims follow the state’s own Medicaid timely filing limit. To join EmblemHealth’s Medicaid network, start with New York Medicaid enrollment, since federal rules require Medicaid managed care network providers to enroll with the state Medicaid program.

Secondary Claims: When EmblemHealth Pays Second

EmblemHealth secondary claim timely filing runs 120 days from the primary carrier’s EOP issue date for participating providers. If the primary payer takes three months to process the claim, your 120 days start on that EOP’s issue date.

Date-stamp the primary EOP or ERA the day it posts, and send the secondary claim within a week. If EmblemHealth asks the member about other coverage and gets no answer within 45 days, EmblemHealth adjudicates the claim anyway, according to its Claims chapter.

EmblemHealth lists wrong insurance information from the member as an unusual occurrence it will consider in a late-filing grievance. You’ll spend less time if you catch the other plan before the visit. A front desk that runs benefit verification before visits finds the forgotten primary plan before the claim goes out.

What to Send With an EmblemHealth Secondary Claim

On an 837 claim, report the primary payer’s payment and adjustments in the coordination of benefits loops, 2320 and 2330, so EmblemHealth can see what the primary paid and why. For paper claims, attach the primary EOB. If you leave the primary data off, expect a COB denial that costs you days you don’t have.

Dental COB follows its own process: EmblemHealth wants a signed claim with the primary carrier’s benefit statement, covered in the dental section below. On the medical side, our guide to CO-22 coordination denials covers the fixes when a payer says another plan should pay first.

EmblemHealth Corrected Claim Timely Filing: 220 Days From the Date of Service

The EmblemHealth corrected claim timely filing limit is the original filing limit plus 100 days. With the standard 120-day limit, that’s 220 days from the date of service. EmblemHealth sets the rule in its Corrected Claim Submission policy, RPC20230037, which it last revised on November 18, 2025, according to the policy’s revision history.

How the Extra 100 Days Works

EmblemHealth’s corrected claim deadline is 220 days from the date of service when the original limit is 120 days. Take a January 15, 2026 date of service. The original claim was due by May 15, 2026, and the corrected claim must arrive by August 23, 2026. EmblemHealth denies a correction that arrives after that date as untimely.

EmblemHealth retired its older guidance that corrected claims had to arrive within 120 days. That July 26, 2021 notice still ranks in search results, and Google’s AI Overview repeats its 120-day figure.

EmblemHealth settled the current wording in 2024. A March 28 revision counted the 100 days from the original adjudication date, and the April 25 revision replaced that with the example of 220 days from the date of service.

The policy lists no exclusions by EmblemHealth company, so the GHI timely filing limit for corrected claims follows the same math. Those 100 days sit on top of the EmblemHealth timely filing limit for the original claim.

The policy’s wording adds 100 days to any original limit, but its one example uses 120 days. For ASO groups or non-participating claims, confirm the math with Provider Services first. Original Medicare has no matching extension: Medicare corrected claim timely filing stays tied to the 12-month limit from the date of service.

How to Submit an EmblemHealth Corrected Claim

EmblemHealth’s current policy doesn’t call for a special EmblemHealth corrected claim form. You send a standard 837 or paper claim with a frequency code and the original claim number, in this order:

1. Wait 30 days after the original submission so EmblemHealth can process it and issue the EOP.
2. Pull the original claim number from the provider portal, the EOP, or the ERA.
3. On an 837P, set CLM05-3 to 7 for a replacement or 8 for a void, and put the original claim number in REF*F8. On an 837I, use bill type 0XX7 or 0XX8.
4. On a paper CMS-1500, enter 7 or 8 in Box 22 with the original number under “Original Ref. No.” On a UB-04, use 7, 5 for late charges, or 8 as the third digit in Box 4, and put the original claim number in Box 64.
5. Resubmit all services on the claim, including lines EmblemHealth already paid.
6. Send it through your clearinghouse or by mail, since EmblemHealth’s provider portal doesn’t accept corrected claims.

A claim correction works like a revised invoice. It replaces the whole original claim, so EmblemHealth wants all the lines back, paid ones included.

You may come across an older GHI EPO/PPO Corrected Professional Paper Claim Form, effective September 1, 2013. The EmblemHealth page that required it now carries a “Retired” label, and the current policy uses Box 22 instead. Call Provider Services before you send that old form with a GHI claim.

Five Corrected Claim Mistakes to Avoid

EmblemHealth’s policy and its June 14, 2024 provider tips name five errors that put a corrected claim at risk of denial or return:

• Placeholder 9s, 0s, or any invalid number in the original claim number field
• A corrected claim used to change the member ID or date of service, where EmblemHealth wants a void and a new claim
• A claim marked “corrected” when you’re sending medical records or an EOB and nothing on the claim changed
• A total charge repeated on each page of a multi-page paper claim, where the total belongs on the last page
• Services for one date of service split across two claim forms

Self-Funded (ASO) Plans With Their Own Filing Limits

Self-funded employer groups that buy administrative services from EmblemHealth, called ASO clients, can set their own claim filing limits. A self-funded group’s limit replaces the EmblemHealth timely filing limit of 120 days for that group’s members, so check the group before you count.

EmblemHealth self-funded (ASO) timely filing limits, status checked October 3, 2026

Sources: EmblemHealth’s current ASO list, dated September 13, 2024, and the 2023 self-funded plan update, dated August 15, 2023.

Check the member’s ID card and the eligibility response for the group name before you apply 120 days. EmblemHealth announces changes to this list through provider news notices, as it did in August 2023 and September 2024, so check that news feed each quarter for EmblemHealth self-funded timely filing updates.

The corrected claim policy’s one example covers the 120-day standard. With a 180-day group, ask Provider Services whether the 100-day extension stacks to 280 days before you count on it. Get the answer in writing, or note the call reference number, in case the corrected claim denies later.

NYCE PPO Timely Filing Limit (2026): 180 Days and a New Payer ID

For NYCE PPO services on or after January 1, 2026, in-network providers have 180 days from the date of service to file, and out-of-network providers have 18 months. You send those claims to UMR under payer ID 26992, and EmblemHealth’s usual payer IDs, 55247 and 13551, don’t apply to them.

What NYCE PPO Is and Who It Covers

EmblemHealth and UnitedHealthcare run NYCE PPO together as partners, and they remain separate companies. The plan covers New York City employees, non-Medicare retirees, and their dependents. Members of the old GHI CBP/Anthem plan moved to NYCE PPO on January 1, 2026, according to the EmblemHealth NYCE PPO update.

Network status depends on where you practice. In 13 downstate New York counties, NYCE PPO uses a custom version of EmblemHealth’s Bridge Program built on the Prime Network and the National Network. Outside those counties, members use UnitedHealthcare’s Choice Plus network, so your UnitedHealthcare contract decides your in-network status there.

The NYCE PPO timely filing limit runs 180 days instead of the EmblemHealth timely filing limit of 120 days. UMR handles the claims, while the City’s plan sets the window. Because UMR timely filing limits vary by employer, a number you’ve seen for another UMR plan won’t fit NYCE PPO.

Billing 2025 Dates of Service for Former GHI CBP Members

Bill services before January 1, 2026 through the old process. Per EmblemHealth’s NYCE PPO FAQ, send those claims to EmblemHealth/Anthem: professional claims under payer ID 13551 to PO Box 2832, New York, NY 10116-2832, and facility claims to PO Box 2833, New York, NY 10116-2833. EmblemHealth Provider Services takes questions at 866-447-9717.

Count 2025 claims under the old GHI CBP plan’s rules, since NYCE PPO’s 180 days starts with January 1, 2026 services. For the Anthem side of the old GHI CBP plan, MedSole’s guide to Anthem timely filing limits covers Anthem’s deadlines.

Behavioral Health and Dental Claims Follow Different Rules

EmblemHealth points behavioral health and dental providers to separate handbooks, and neither one uses the standard EmblemHealth timely filing limit. Carelon Behavioral Health’s handbook sets 90 calendar days from the date of service or discharge, and EmblemHealth’s dental handbook asks for claims within 30 days and no later than 365 days.

Carelon Behavioral Health Timely Filing

Carelon Behavioral Health gives participating providers 90 calendar days from the date of service, or from the discharge date for an inpatient stay, unless the provider agreement says otherwise. That’s the Carelon behavioral health timely filing limit in the Carelon Behavioral Health handbook that EmblemHealth links to, last updated March 1, 2023.

Send behavioral health claims to Carelon instead of EmblemHealth’s medical payer IDs. Paper claims go to EmblemHealth Behavioral Health Claim Services, PO Box 1850, Hicksville, NY 11802-1850, and EmblemHealth’s directory lists 800-235-3149 for Carelon claims.

EmblemHealth’s 100-day corrected claim extension sits in an EmblemHealth reimbursement policy, so don’t assume it carries over to Carelon. For the Carelon timely filing limit for corrected claims, check your Carelon agreement or call Carelon before you resubmit.

EmblemHealth Dental Timely Filing

File EmblemHealth dental claims within 30 days of the service date and no later than 365 days, per the EmblemHealth dental handbook, version 3/26. EmblemHealth may still pay a late claim if filing on time was “not reasonably possible” and you filed as soon as you could.

Submit electronic dental claims under payer ID 13551, or mail paper claims to EmblemHealth, Dental Claims, PO Box 2838, New York, NY 10116-2838. If EmblemHealth is the secondary carrier, send a signed claim with a copy of the primary carrier’s benefit statement.

Some group plans set longer windows. The 1199SEIU dental FAQ tells dentists to file EmblemHealth dental claims for its members within 30 days and no later than 18 months. MedSole’s dental billing services handle dental claims from insurance verification through payment posting.

How to Appeal an EmblemHealth Timely Filing Denial

EmblemHealth lets providers challenge a commercial or Child Health Plus claim denied for missing the EmblemHealth timely filing limit through its practitioner grievance process. You have 45 calendar days to file. To win, show that the late claim was an unusual occurrence and that your practice files on time as a pattern.

Who Qualifies for a Late-Filing Reconsideration

EmblemHealth’s Commercial and CHP dispute chapter sets a two-part test: the late submission was an unusual occurrence, and you have a pattern of filing claims on time. New York Insurance Law 3224-a(h) applies the same test to the insurers it regulates. EmblemHealth gives four examples of an unusual occurrence:

• Medicaid reclamation
• Wrong insurance information from the member
• Coordination of benefits issues
• Retroactive reinstatement of the member

EmblemHealth’s Medicaid dispute chapter applies the same standard to Medicaid managed care claims, and the Medicare dispute chapter applies it to Medicare Advantage claims. Expect CARC 29 on the remittance for a late-filing denial; X12 defines it as “The time limit for filing has expired.”

How to File the Grievance

The EmblemHealth appeal timely filing limit is 45 calendar days from the event, per EmblemHealth Table 21-1. For a late-filing denial, count from the date on the denial EOP to stay safe. The portal route needs no separate provider dispute form, and EmblemHealth prefers it:

1. Sign in to the provider portal at emblemhealth.com/providers, open the Claims tab, click Search Claims, and click Ask a Question on the Claims Detail page.
2. Choose the Claims and Payments category, explain the denial, attach your documents, and submit.
3. If that inquiry doesn’t resolve the denial, click your User Profile icon, open My Messages, find the inquiry, and click Follow-up.
4. Choose the Grievances & Appeals category, add your explanation and attachments, and submit.
5. For a paper grievance, mail it to PO Box 2844, New York, NY 10116-2844, addressed to the department Table 21-1 lists for the member’s plan.

Attach the denial EOP, a short letter that names the unusual occurrence, proof of that occurrence, and your proof of timely filing for the original attempt. Add a filing log that shows your on-time pattern across recent months.

EmblemHealth acknowledges a grievance within 15 days and decides within 45 days of receipt. If you win, you’ll get a remittance advice. For questions, call 800-447-8255 for HIP, 877-244-4466 for GHI HMO, or 212-501-4444 for EPO/PPO plans.

The 25% Reduction and the 365-Day Cutoff

EmblemHealth can reduce payment by up to 25% even when you win. Its dispute chapters also let EmblemHealth deny the late claim in full. Watch the remittance for the cut; X12’s claim adjustment reason codes include CARC B4, “Late filing penalty,” though EmblemHealth may code the reduction another way.

New York law sets a hard stop. Under Insurance Law 3224-a(h), the reconsideration right doesn’t apply to claims submitted 365 days or more after the date of service. Past day 365, a commercial claim under that law has no unusual-occurrence argument left.

Can You Bill the Patient?

No. Participating providers can’t bill the patient. EmblemHealth’s Claims chapter bars network providers from billing members for any claim denied for late submission, so the balance is a write-off unless your grievance succeeds. The same rule covers claims EmblemHealth denies for inaccurate coding or missing authorization.

What to Keep as Proof of Timely Filing

EmblemHealth’s timely filing and grievance pages don’t list specific proof documents, so build your file around the date EmblemHealth received each claim. The same records prove you met the EmblemHealth timely filing limit and show the on-time pattern a late-filing grievance requires.

• 999 acknowledgment: your clearinghouse accepted the file
• 277CA claim acknowledgment: the payer accepted the claim, with a date
• Clearinghouse batch report: the submission date and payer name
• EOP or 835 ERA: EmblemHealth’s received and processed dates
• Certified mail receipt with a copy of the paper claim: proof for paper submissions
• Portal claim inquiry messages: the date you raised the issue with EmblemHealth
• Monthly filing log: the on-time pattern the grievance test asks for

Store these records by date of service, and hold them at least until day 365, when New York’s reconsideration right ends. Keep the payer-level 277CA next to the clearinghouse report, since the 277CA shows what EmblemHealth’s system accepted. If your clearinghouse doesn’t return payer 277CA reports, see our medical billing clearinghouses compared guide.

EmblemHealth Payer IDs, Claims Addresses, and Phone Numbers

The EmblemHealth payer ID and EmblemHealth claims address depend on which EmblemHealth company insures the member and on the claim type. Use the paper addresses below unless the member’s ID card lists a different one.

Emblem Health payer ID and claims address by company, verified October 3, 2026

Source: EmblemHealth Claims Contacts directory, plus the EmblemHealth dental handbook, HealthCare Partners’ EmblemHealth claims page, and EmblemHealth’s NYCE PPO FAQ.

Providers searching for an Emblem Health claims address or GHI claims address often land on PO Box 3000, the box for member-submitted claims. The claims mailing address for GHI professional claims is PO Box 2832, and GHI facility claims go to PO Box 2833.

For HIP and EmblemHealth Insurance Company members, the EmblemHealth provider phone number for claims is 866-447-9717. The GHI provider phone number for claims is 212-501-4444, the same line EmblemHealth lists for EPO/PPO grievance questions.

EmblemHealth’s EDI transactions page names TriZetto Provider Solutions as its preferred connection and says claims from clearinghouses such as Availity also reach EmblemHealth. The page shows a last update of January 2, 2020, so confirm the route with your clearinghouse.

If you’re weighing how to submit claims to EmblemHealth, file electronic 837P, 837I, or 837D transactions when you can. Electronic files leave a dated acknowledgment trail, and paper claims leave you a mailing receipt at best.

A claim mailed to the wrong box or sent under the wrong payer ID can sit for weeks before anyone notices, and the clock on the EmblemHealth timely filing limit keeps running. MedSole’s claims submission services team tracks each claim from transmission through acknowledgment, so no claim sits in an unknown state.

How to Keep EmblemHealth Claims Inside the Filing Window

Set up the EmblemHealth timely filing limit in your practice management system as a 120-day default, then add separate rules for ASO groups, NYCE PPO, Carelon, dental, and the 220-day corrected claim window. Sort the aging report by days left before the deadline, and work the shortest number first.

Build a New York Payer Deadline Matrix

Time limits on insurance claims differ across the New York payers a typical practice bills side by side. Put them in one matrix your team can check in seconds:

New York payer deadline matrix, verified October 3, 2026

Load these timely filing deadlines into your practice management system as payer rules, and recheck the matrix whenever a payer posts a provider notice. The Fidelis timely filing limit is the tightest one here for initial claims, at 90 days, so Fidelis claims belong at the top of the work queue.

When Outsourcing Makes Sense, and What It Costs

Consider handing EmblemHealth billing to a specialist team when one of these shows up in your aging report or denial log:

• EmblemHealth claims aging past 90 days with no payer response
• The same corrected claim denied twice
• No one on staff tracking ASO groups or the NYCE PPO cutover

Comparing billing companies comes down to four terms: the percentage of collections, what that percentage includes, setup fees, and contract length. MedSole publishes all four:

At that rate, MedSole’s outsourced medical billing covers eligibility verification, coding review, payment posting, and monthly reporting along with the claim work. First claims go live within 7 to 10 business days of onboarding, so a switch uses a small slice of a 120-day window.

For a provider who needs to join EmblemHealth’s network, MedSole’s credentialing from $99 per payer application covers the enrollment paperwork, and a specialist calls the payer each week.

EmblemHealth Timely Filing FAQs

What is the EmblemHealth timely filing limit?

The EmblemHealth timely filing limit is 120 days from the date of service for participating providers. If EmblemHealth pays second, the 120 days start on the primary payer’s EOP issue date.

Non-participating providers get 18 months for commercial claims, 15 months for Medicaid and Child Health Plus, and 365 days for Medicare. A participation agreement or self-funded plan can replace the EmblemHealth timely filing limit for its members.

What is the EmblemHealth corrected claim timely filing limit?

The EmblemHealth corrected claim timely filing limit is the original limit plus 100 days, which comes to 220 days from the date of service at the 120-day standard.

EmblemHealth’s Corrected Claim Submission policy, last revised November 18, 2025, sets the rule. Wait 30 days for the original claim to process, and include the original claim number, or EmblemHealth will deny the corrected claim.

Is the GHI timely filing limit different from EmblemHealth’s?

No. The GHI timely filing limit for participating providers is 120 days, since GHI now operates as EmblemHealth Plan, Inc. and follows the EmblemHealth timely filing limit.

Older EmblemHealth manuals list 365 days for GHI in-network claims, and that number still shows up in search answers. If a legacy GHI agreement in your files states 365 days, follow the agreement; otherwise, use 120 days.

What is the EmblemHealth appeal timely filing limit?

The EmblemHealth appeal timely filing limit is 45 calendar days from the event for a commercial or Child Health Plus practitioner grievance, per Table 21-1.

You’ll need to show an unusual occurrence and a pattern of on-time filing. EmblemHealth decides within 45 days and can cut payment by up to 25% if you win. Under New York law, the reconsideration right ends for claims submitted 365 days or more after the date of service.

Can you bill a patient for an EmblemHealth timely filing denial?

No, not if you participate with EmblemHealth. EmblemHealth’s Claims chapter bars network providers from billing members for claims denied for late submission.

Write the balance off unless a grievance overturns the denial. Track these write-offs by cause, so you can fix the step that let the claim age past day 120.

What is the EmblemHealth payer ID?

The EmblemHealth payer ID depends on the company on the member’s card. HIP and EmblemHealth Insurance Company claims use 55247, and EmblemHealth Plan, Inc. (the former GHI) and dental claims use 13551.

GHI-branded HMO claims take 25531, Vytra-branded HMO claims take 22264, and NYCE PPO claims for services on or after January 1, 2026 go to UMR under payer ID 26992.

Does EmblemHealth use Availity?

Yes. Claims sent through Availity reach EmblemHealth, though EmblemHealth names TriZetto Provider Solutions as its preferred EDI connection. HealthCare Partners, which manages care for some EmblemHealth members, takes claims through Availity under payer ID 11328. Confirm the route with your clearinghouse; EmblemHealth’s EDI page dates to 2020.

What is timely filing, and what does TFL mean in medical billing?

Timely filing is the deadline a payer sets to receive a claim, counted from the date of service or another start date in the payer’s rules. TFL in medical billing stands for timely filing limit.

The Emblem timely filing limit, or Emblem TFL limit as some billers write it, is 120 days for participating providers. A claim that misses it comes back denied, with CARC 29 on the remittance.

How much does it cost to outsource EmblemHealth billing and credentialing?

Costs vary by company and pricing model. At MedSole RCM, medical billing starts at 2.99% of monthly collections, with no setup fees and no long-term contracts.

That rate includes claims submission, denial management, and AR follow-up, and the same pricing covers your EmblemHealth claims along with your other payers. Credentialing starts at $99 per payer application. The full-service billing at 2.99% page lists each service the rate includes.