NY Bridge Plan To Be Administered Under Federal Program Effective July 1, 2013

Date Issued: 6/20/2013

The NY Bridge Plan was administered by Group Health Incorporated (GHI), an EmblemHealth company, under agreements with the US Department of Health & Human Services (HHS) and the New York State Department of Financial Services. Effective July 1, 2013, the Federal pre-existing condition insurance plan (PCIP) will assume administration of this program. Both EmblemHealth and HHS have notified enrolled members that, as of July 1, 2013, they will be covered by the Federal PCIP program.

To effectively transition members to the Federal PCIP, please make note of the following:

  • Required use of the Federal PCIP’s network: Federal PCIP patients may receive care for most covered services from any willing provider of their choice. However, the Federal PCIP’s network must be used for the following services:
    • Prescription drugs
    • Durable medical equipment
    • Organ and tissue transplants

  • Plan deductibles: Deductibles applied under the NY Bridge Plan will not carry over to the Federal PCIP. The member will be responsible for meeting their full deductible under the Federal PCIP.

  • Prior approvals: Check with the Federal PCIP to see if your prior approvals are still valid after July 1, 2013. A new prior approval may be required for certain services, even if previously authorized by EmblemHealth.

  • Inpatient stays: Inpatient stays that start on or before June 30, 2013, and continue on or after July 1, 2013, require a new prior approval for continued coverage by the Federal PCIP.
Please see the interim final rule issued by CMS on Friday, May 17, 2013, for more information on payment rates for covered services provided to individuals enrolled in the Federal PCIP.

Claims Submissions

Inpatient Stays
Please submit claims for these stays as follows:

  • For confinement days up to and including June 30, 2013, that are paid a per diem rate, send claims to:

    GHI Claims
    PO Box 2832
    New York, NY 10116-2832

    For electronic claims, use electronic payor ID 13551.
  • For confinement days that occur on or before June 30, 2013, and continue on or after July 1, 2013, that receive a DRG rate, submit claims to:

    GHI Claims
    PO Box 2832
    New York, NY 10116-2832

    For electronic claims, use electronic payor ID 13551.
  • For confinement days on or after July 1, 2013, that are paid a per diem rate, send claims to the Federal PCIP at:

    PCIP
    PO Box 30783
    Salt Lake City, UT 84130-0783

    For electronic claims, use EDI submitter # 39026.

Outpatient Services
Please submit claims for these services as follows:

  • For dates of service up to and including June 30, 2013, please send claims to:

    GHI Claims
    PO Box 2832
    New York, NY 10116-2832

    For electronic claims, use electronic payor ID 13551.
  • For dates of service on or after July 1, 2013, submit most claims* to the Federal PCIP at:

    PCIP
    PO Box 30783
    Salt Lake City, UT 84130-0783

    For electronic claims, use EDI Submitter # 39026.

*Submit transplant/DME/dialysis claims to:
    PCIP
    PO Box 300
    Independence, MO 64051-0300

    For electronic claims, use EDI Submitter # 57254.

More Information

If you have questions about this transition, please forward your inquiries by signing in to our secure site and proceeding to our Message Center. When composing your message, select “General Information” as the category in the drop-down menu on the “Ask a Question” page.

You may also refer to the PCIP brochure or Web site or contact the Federal PCIP directly at 1-800-220-7898 , Monday through Friday from 8 am to 6:30 pm, EST.