1199SEIU National Benefit Fund Dental Transition to EmblemHealth — FAQs

The 1199SEIU National Benefit Fund (NBF) has elected EmblemHealth to administer its dental benefit beginning April 1, 2017. The NBF’s own dental network will no longer be maintained, and your Provider Agreement with the NBF will be terminated effective April 1, 2017.

The Benefit Fund aims to make the transition as seamless as possible and will work with EmblemHealth to ensure minimal disruption. We have created this FAQ to assist you during the transition.

Why is the NBF discontinuing its dental network?

This change will improve the benefits of our members and provide a larger contracted network.

Who will administer dental coverage for the NBF effective April 1, 2017?

The NBF has contracted with EmblemHealth to administer its dental benefits beginning April 1, 2017.

Do I need to contract directly with EmblemHealth?

Yes. If you are not already a participating provider in the EmblemHealth Preferred Dental network, the NBF encourages you to join the network in order to continue to provide service to NBF members and their beneficiaries. To join EmblemHealth’s Preferred Dental network, please contact EmblemHealth at DentalProviders@EmblemHealth.com or at www.EmblemHealth.com (click the “Provider” tab, then select “For Dental Providers”).

I just completed recredentialing with the NBF; will I need to go through the process again?

Yes. Your credentialing status with the NBF will not be transferred to EmblemHealth. If you are already participating in the EmblemHealth Preferred Dental network, you will not need to re-apply. To verify your participation in the EmblemHealth Preferred Dental network, please contact EmblemHealth at DentalProviders@EmblemHealth.com or at www.EmblemHealth.com (click the “Provider” tab, then select “For Dental Providers”).

I am an EmblemHealth participating dentist; do I have to do anything to be considered a participating provider for NBF members?

If you are already a participating provider in the EmblemHealth Preferred Dental network, you will not have to do anything to continue to provide service to NBF members and their beneficiaries. To verify your participation status with EmblemHealth, please search EmblemHealth’s Preferred Dental provider directory at http://psearch.ghi.com/ProviderSearchEHGHI/Search.aspx?Plan=PPO|4|110&Network=06.

I am an NBF participating dentist; will my contracted rates be transferred to EmblemHealth?

No. Effective April 1, 2017, payment will be in accordance with the EmblemHealth Preferred Dental network rates for dentists participating in that network. If you are not a participating provider in the network, EmblemHealth will contact you directly to initiate the recruitment process.

I am not an NBF participating dentist; at what rate will my claims be reimbursed?

If you are not a participating provider in the EmblemHealth Preferred Dental network, your reimbursement will be based upon EmblemHealth’s out-of-network reimbursement schedule and payment will be sent to the policyholder.

How do I contact EmblemHealth about services provided on or after April 1, 2017?

You may contact EmblemHealth at DentalProviders@EmblemHealth.com or at www.EmblemHealth.com (click the “Provider” tab, then select “For Dental Providers”).

Will NBF members get new Dental ID cards?

Dental ID cards will be issued to all eligible NBF members in the following classes:

  • Wage Class 1 members and dependents
  • Wage Class 3 members who have opted for dental benefits
  • Early retirees who have opted for dental benefits

Whom do I call about services provided before April 1, 2017?

Please contact the Benefit Fund via our customer service line or our Interactive Voice Response system:

  • Provider Relations Call Center: (646) 473-7160
  • Interactive Voice Response system: (888) 819-1199

Where do I submit claims for services provided before April 1, 2017?

Please mail ADA claims to:

1199SEIU Benefit Funds
PO Box 1149
New York, NY 10108-1149

Where do I submit claims for services provided on or after April 1, 2017?

Please submit these claims to EmblemHealth online at www.emblemhealth.com/en/Providers/Claims-Corner  (Submission Payer ID: 13351). You may also submit paper claims to the following address:

EmblemHealth
PO Box 2838
New York, NY 10116-2838

For more information, please contact EmblemHealth at DentalProviders@EmblemHealth.com or at   www.EmblemHealth.com (click the “Provider” tab, then select “For Dental Providers”).

Can one claim be submitted with services that were provided before, on and after the April 1, 2017, transition date?

For outpatient service claims, the Benefit Fund will not accept claims with dates of service that span April 1, 2017. Similar to the Centers for Medicare & Medicaid Services, the Benefit Fund requires providers to split the claim so that claims with dates of service March 31, 2017, and earlier will be accepted by the Fund, while claims with dates of service on April 1, 2017, and later will be accepted by EmblemHealth.

When should I submit claims for services provided before April 1, 2017?

Please submit these claims to the Benefit Fund no later than one year from the date the service was provided.

When should I submit claims for services provided on or after April 1, 2017?

Please submit these claims to EmblemHealth within 30 days of the service date, and no later than 18 months after the service date. If you do not file a claim on time, EmblemHealth may still pay the claim if it is determined that it was not reasonably possible for you to have filed the claim on time and that the claim was filed as soon as possible. For more information, please contact EmblemHealth at DentalProviders@EmblemHealth.com or at  www.EmblemHealth.com (click the “Provider” tab, then select “For Dental Providers”).

I am not a participating EmblemHealth dentist. How will my claims be paid?

Claims submitted by providers who are not in the EmblemHealth Preferred Dental network will be paid according to EmblemHealth’s out-of-network reimbursement schedule and payment will be sent to the policyholder.

I am not a participating EmblemHealth dentist; whom should I contact about payment of my claims for services on or after April 1?

For services provided on or after April 1, please visit www.EmblemHealth.com (click “Provider” tab, then select “For Dental Providers”).

What if an NBF member or a non-participating provider wants to appeal a service provided before April 1, 2017?

Members and non-participating providers must submit these appeals to the NBF within 180 days of the receipt of an adverse decision.

What if an NBF member or a non-participating provider wants to appeal a service provided on or after April 1, 2017?

Members and non-participating providers must contact EmblemHealth at DentalProviders@EmblemHealth.com or at www.EmblemHealth.com (click “Provider” tab, then select “For Dental Providers”).

Provider appeals—including pre-determinations— should be sent to the following address:

EmblemHealth’s Grievance and Appeal Department
PO Box 2844
New York, NY 10116-2844

Are the members’ dental benefits changing?

All NBF members will have a $3,000 annual maximum dental benefit per calendar year. This $3,000 maximum will cover what NBF has paid for services provided from January 1, 2017, to March 31, 2017 — and what EmblemHealth will pay for services provided on or after April 1, 2017, up to December 31, 2017.

What will happen to dental pre-determinations that were approved to begin on April 1, 2017 or later?

Please contact EmblemHealth to initiate a new pre-determination review for services that were approved for April 1, 2017, or later.

What happens to treatments that were approved and started before April 1 and would be completed after April 1?

If you are currently a participating NBF dentist and are not a participating provider in EmblemHealth’s Preferred Dental network, please ask the patient to complete and submit an EmblemHealth Transition of Care Request Form. For orthodontic treatment, you will need to submit a new pre-determination of benefits to EmblemHealth. Both forms should be mailed to the address below:

EmblemHealth Plans
PO Box 2838
New York, NY 10116-2838

Where should claims be submitted for dental treatments that are in progress?

Claims for dates of services on or before March 31, 2017, should be submitted to:

National Benefit Fund
PO Box 1149
New York, NY 10108-1149

Claims for dates of service on or after April 1, 2017 should be submitted to:

EmblemHealth
PO Box 2838
New York, NY 10116-2838

Are claims and claims history being transferred to EmblemHealth?

Claims history will be transferred to EmblemHealth. For inquiries related to claims and claims history for dates of service prior to April 1, 2017, please contact the Benefit Fund:

  • Provider Relations Call Center: (646) 473-7160
  • Interactive Voice Response system: (888) 819-1199

For inquiries related to claims and claims history for dates of service on or after April 1, 2017, please contact EmblemHealth at DentalProviders@EmblemHealth.com or at www.EmblemHealth.com (click the “Provider” tab, then select “For Dental Providers”).

Whom do I contact if I need a check reissued?

For dates of service prior to April 1, 2017, you should contact our dedicated Provider Call Center at (646) 473-7160. For dates of service after April 1, 2017, please contact EmblemHealth at DentalProviders@EmblemHealth.com.

Whom do I contact for a copy of an EOP for services prior to April 1, 2017?

You should contact our dedicated Provider Call Center at (646) 473-7160. For an EOP copy for dates of service on or after April 1, 2017, you should contact EmblemHealth at DentalProviders@EmblemHealth.com.

Whom do I contact for a copy of a 1099 for services prior to April 1, 2017?

You should contact our dedicated Provider Call Center at (646) 473-7160. For a 1099 copy for dates of service on or after April 1, 2017, you should contact EmblemHealth at DentalProviders@EmblemHealth.com or visit EmblemHealth’s website at www.EmblemHealth.com.

Are the member benefits starting all over again as of April 1, 2017?

No, annual benefits will not start over as of April 1, 2017. All NBF members will have a $3,000 annual maximum dental benefit per calendar year. This $3,000 maximum will cover what NBF has paid for services provided from January 1, 2017, to March 31, 2017—and what EmblemHealth will pay for services provided on or after April 1, 2017, up to December 31, 2017.

Will EmblemHealth have eligibility and benefits history for services members received prior to April 1, 2017?

Yes. EmblemHealth will have eligibility and benefits history for services provided prior to April 1, 2017.

 
If you have additional questions about the transition to EmblemHealth, please call our Provider Relations Call Center at (646) 473-7160 or email Providers@1199Funds.org.