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How Do I...
  • How Do I...

    Quick answers to basic questions about how to do business with EmblemHealth.

    You can find EmblemHealth medical policies in Clinical Corner. These medical policies reflect some of the information we consider when determining the medical necessity of certain services or supplies.

    • Submit electronic claims to EmblemHealth using the Payor IDs listed in the Claims Contacts chart in the Directory chapter.
    • Submit paper claims (CMS-1500 forms) to the addresses listed in the Claims Contacts chart, unless otherwise indicated on the member’s ID card.

    Provider Relations Identification System (PRIS) Number is an assigned number that distinguishes each provider’s participating service location. Each participating service location, credentialed with EmblemHealth (HIP) receives a PRIS Number.

    If a provider does not know their PRIS Number they may contact an EmblemHealth Customer Care Provider Advocate at 1-866-447-9717 or they may refer to the provider directory by following the directions below:

    1. Go to emblemhealth.com, click Members
    2. Select Find a Doctor or Hospital on the left navigation bar, then click “Search Now”
    3. Enter the site as a visitor & enter the zip code of the office location
    4. Select the Prime Network & enter the providers name click enter
    5. All of the providers with that name will be listed and their PRIS number
    6. Click on the providers name and get all of the information associated with him/her to include their PRIS number (which is also referred to as a Directory number)

    The most efficient, safe and streamlined way to do business with EmblemHealth is through our secure website. It also is the quickest, most cost-effective and most environmentally friendly way to receive and send information. So, if you haven’t already, please sign up for secure access today. Just go to our provider home page at emblemhealth.com/Providers. In the yellow “Sign In to My Account” box, click “Register for Access” and complete the required fields.

    Note: HIP providers have a Provider Number (aka PRIS#) for each of their locations and must register each Provider Number separately. GHI providers have only one Provider Number, but must register for each of their TINs separately.

    Need Help Finding Your Provider Number(s)?

    • Go to our Find a Doctor search at emblemhealth.com/find-a-doctor.
    • Do a Visitor Search by entering your ZIP code.
    • If you are a HIP provider, select an HMO plan in which you participate (e.g., HIP Prime HMO). If you are a GHI provider, select an EPO/PPO plan in which you participate (e.g., EmblemHealth PPO).
    • Search by your name.
    • On the results page, click on your name to access your Provider Number, listed as Directory Number on the screen. If you are a HIP provider and have multiple locations, click “See Other Locations” and then “See Details” for each location to gather all of your Provider Numbers.

    Need Help Registering?

    • If you are a HIP provider, you need to register each office location separately, using your location-specific Provider Numbers. So if you have three locations, you will need to complete the registration process three times.
    • If you are a GHI provider, you need to register each TIN used to submit claims separately. So if you have two TINs, you will need to complete the registration process two times. Use the same Provider Number for each registration.
    • If you are both a HIP and GHI provider, please follow the instructions in the first two bullets.

    Once Registered, You Can:

    • Check your network participation.
    • Update your practice information.
    • Set the level of access for your staff.
    • Appoint a staff member to act on your behalf.
    • Check member benefits and eligibility and manage referrals and prior approval.

    For benefit plans that require referrals, the referral must be made to a network specialist in the member’s benefit plan. To check specialist participation, use our Find a Doctor tool. Vytra providers should use the Vytra Provider Directory to check specialist participation. Please note: GHI HMO and Vytra benefit plans following same rules as HIP underwritten Networks and Plans.

    A member’s managing entity determines the prior approval procedure to follow:

    HIP- underwritten Networks and Plans

    • Sign in to our secure website with your PRIS number (which is also referred to as a Directory number in Find a Doctor tool)
    • Call 1-866-447-9717
    • Fax to 1-866-426-1509 for DME; 1-866-215-2928 for all other prior approval requests

    Before providing care, specialists, facilities and ancillary providers must verify that a prior approval has been issued. To do this:

    • Sign in to the our secure website with your PRIS number
    • Call the IVR system at 1-866-447-9717
    • Review the Concurrent Review Status Report on our secure website (for hospitals and skilled nursing facilities only)

    GHI- underwritten Networks and Plans

    • Sign in to our secure website with your TIN
    • Call 1-212-615-4662 in New York City or 1-800-223-9870 outside New York City
    • Fax to 1-212-563-8391

    Prior approval requirements and procedures may differ for certain ASO accounts. Contact the administrator listed on the member’s ID card for confirmation.


    HealthCare Partners

    • Call 1-800-877-7587
    • Fax to 1-888-746-6433


    Montefiore CMO

    • Call 1-888-666-8326; 1-800-401-4822 for behavioral health services

     

    For some programs, we have delegated prior approval to our partners as follows:

    Behavioral Health Program
    All EmblemHealth networks and plans.

    • Sign in to www.valueoptions.com
    • Call Beacon at 1-888-447-2526 for HIP- underwritten networks and plans; 1-800-692-2489 for GHI- underwritten networks and plans

    Cardiology Imaging Program
    HIP- underwritten networks and plans and Medicare Choice PPO Network-based plans.

    • Sign in to www.evicore.com
    • Call eviCore at 1-866-417-2345 for HIP- underwritten networks and plans; 1-800-835-7064 for EmblemHealth Medicare PPO Choice PPO Network plans and the Prime Network’s GHI HMO plan
    • Fax to eviCore at 1-888-622-7369

    Chiropractic Program
    All EmblemHealth networks and plans.

    • Sign in to www.palladianhealth.com
    • Call Palladian at 1-877-774-7693
    • Fax to Palladian at 1-716-712-2802 for HIP- underwritten networks and plans; 1-716-712-2817 for GHI- underwritten networks and plans and the Prime Network’s GHI HMO plan; 1-716-712-2803 for Vytra plans

    Injectable Drug Utilization Management Program
    HIP- underwritten networks and plans and Medicare Choice PPO Network-based plans.


    Outpatient Physical and Occupational Therapy Program
    HIP- underwritten networks and plans.


    Radiation Therapy Program
    HIP- underwritten networks and plans and Medicare Choice PPO Network-based plans.

    • Sign in to www.evicore.com
    • Call eviCore at 1-866-417-2345 for HIP- underwritten networks and plans; 1-800-835-7064 for GHI- underwritten networks and plans
    • Fax to eviCore at 1-888-622-7369

    Radiology Program
    All EmblemHealth Networks and Plans.

    • Sign in to www.evicore.com
    • Call eviCore at 1-866-417-2345 for HIP- underwritten networks and plans; 1-800-835-7064 for GHI- underwritten networks and plans and the HIP- underwritten Prime Network’s GHI HMO plan
    • Fax to eviCore at 1-800-540-2406

    EmblemHealth Spine Surgery and Pain Management Therapy Procedures Utilization Management Program
    HIP- underwritten networks and plans.

    To request prior approval you must complete and Fax the correct OrthoNet EmblemHealth Fax Request form for the services you are requesting along with any supporting clinical notes including relevant clinical history, reports of imaging and other pertinent clinical information to: 1-844-296-4440. For more information, please call OrthoNet at 1-844-730-8503.

    Reconsiderations and Reopening Requests for denied prior approvals denied by OrthoNet may be mailed to OrthoNet at the following address:

    OrthoNet
    EmblemHealth Appeals
    P.O. Box 5046
    White Plains, NY 10602-5046

    Pre-Certification Process for GHI PPO City of New York Employees/Non-Medicare Eligible Retirees with GHI PPO Benefits

    Effective January 1, 2016, utilization management for the City of New York employees and non-Medicare eligible retirees with GHI PPO benefits will be managed by Empire BCBS for inpatient and outpatient services. EmblemHealth will process pre-certification requests for the following:

    • Home Health Care
    • Home Infusion Therapy (billed by a home infusion specialist)
    • MRI/MRA/PET/CAT/NUCLEAR CARDIOLOGY
    • Nutritional Supplements and Enteral Formulas

    To request pre-certification from EmblemHealth you may utilize our secure provider website: emblemhealth.com/Providers, or fax your request to 1-212-563-8391, or call the Coordinated Care Intake department at 1-800-223-9870.

    To request pre-certification from Empire BCBS, please call 1-800-521-9574.

    We recommend that you periodically review the information we have on file for you. To do this, sign in to our secure website and select "Provider Profile" or "Practice Profile" from the left navigation panel.

    Helpful tip: The Provider/ Practice Profile screen also includes information about the networks you participate in. You must accept a patient’s benefit plan if the network shown on the member’s ID card, on the eligibility details screen on our secure provider website or shared through our IVR system, matches one of your participating networks. According to our standard contracting guidelines, if you are in a network, you may see members with any benefit plan associated with that network.

    Keeping your information current ensures we send your claims payments and other important correspondence to the correct address. It also helps our members contact you at your current location. If you don’t have access to a computer, please fax any changes to our Provider Modifications team at 1-877-889-9061. You may also mail your changes to:

    Provider Modifications Team
    55 Water Street,
    6th Floor,
    New York, New York, 10041-8190

    If you have questions about your network participation, please sign in to our secure provider website and go to our Message Center. Select “General Information” as the category from the drop-down menu on the “Ask a Question” page. Thank you for your partnership with EmblemHealth.

    Religio-Cultural Competency

    Properly addressing religion is a key element of providing patient-centered care and improving health outcomes and patient and family satisfaction. That’s why we partnered with the Tanenbaum Center for Interreligious Understanding, a secular nonprofit organization dedicated to overcoming religious bias and intolerance, to create resources that help medical practitioners understand how religious beliefs and practices intersect with medical science. For more information, please see our cultural competency continuing education and resources webpage.

    Language Line: Interpreter Service

    Free multi-language interpreter service is available to assist providers and their patients. Services are available in over 200 languages, including English, Spanish, Chinese Mandarin, Chinese Cantonese, Tagalog, French, Vietnamese, German, Korean, Russian, Arabic, Italian, Portuguese, French Creole, Polish, Hindi and Japanese. To access an interpreter, providers may call 1-866-447-9717 and a Provider Customer Care Advocate will assist you.

    The plan name “Enhanced Care Plus” and the network name “Enhanced Care Prime” will display on member ID cards. The Member Eligibility Details screen in the secure provider portal and the PCP Panel Report will indicate HARP membership. Members assigned PCPs will be sent letters regarding members Heath Home assignments. If you do not have the assignment letter and need to identify your patient’s Health Home, please call 1-866-447-9717.

    It is very important for our physical health network practitioners to be aware of their patients’ mental health and substance use disorders. We ask our PCPs to screen their patients for depression and other potential issues and to take these diagnoses into consideration when developing treatment plans. Where possible, please identify and coordinate care with your patient’s behavioral health providers. For more information on HARP and other Medicaid Managed Care services, please see the Medicaid section of the Provider Network and Member Benefit Plans chapter.

    Helpful tip: As a reminder, providers who participated in the Medicaid Prime Network, now fully participate in the Enhanced Care Prime Network. Our rebranded network is associated with our Medicaid Managed Care plan – Enhanced Care, our HARP plan – Enhanced Care Plus and our Basic Health plan – Essential Plan. If the member calls you and you do not participate in their benefit plan, please direct them back to our website.

    Sign in to our secure provider website and proceed to the Message Center. When you compose your message, select “General Information” as the category in the drop-down menu on the "Ask a Question" page.

    NYC has developed a series of informative Action Kits and Handbooks to help primary care providers address key health issues with their patients.

    Public Health Action Kits for Providers - contain clinical tools, resources for providers and patient education materials, which promote evidence-based best practices and chronic disease management. These materials are available for health care providers and their practices to help improve patient care related to key public health challenges. Clinical topics have been chosen largely because of their anticipated impact on morbidity and mortality.

    Additional Handbooks are available in the Primary Care Innovation Network Resource Library (sponsored by PCDC).

    For times when you are not available and your EmblemHealth members need access to in-person urgent care and use of the ER is not appropriate, please provide them with a list of the Urgent Care Centers they have access to.

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