Claims Corner

See If You Qualify for a Primary Care Rate Increase

Under the Affordable Care Act, eligible primary care providers will be reimbursed at Medicare rates for Evaluation and Management codes (99201-99499) and Vaccine Administration codes (90460, 90461, 90471, 90472 and 90474) for services rendered to EmblemHealth Medicaid managed care members. To determine if you are eligible for this increased reimbursement, you must submit the New York State Medicaid Fee for Service and Managed Care Primary Care Rate Increase attestation form, available on the NYSDOH Web site. More

Reminder: New Accreditation and Certification Requirements for Outpatient Diagnostic Imaging Began July 1

Effective July 1, 2013, the EmblemHealth Outpatient Diagnostic Imaging Self-Referral Payment Policy (SRPP) replaced HIP's Radiology and Cardiology Imaging Privileging programs. The policy defines the minimum accreditation and certification requirements by specialty for diagnostic imaging conducted in an office setting (POS 11). Referral and prior approval rules continue to apply where applicable. Certain groups are excluded from this policy. More

Welcome to the New emblemhealth.com

We've made it easier for you to search our site for the information you need. Here are some of the improvements you'll see:

  • New look and feel: We've redesigned our site to ease your navigation through it. The latest news and announcements are right on the provider home page. And the information you use most often — Provider Manual, Claims Corner and Medical Policies — is now accessible from the main navigation bar at the top of each provider page. Experience the new provider home page.

Monthly Webinars for Practitioners and Office Staff

Topics include:

  • Navigating our secure Web site
  • Using medical and payment policy tools
  • Identifying EmblemHealth member ID cards and member benefits

Who should attend: Practitioners and their staff members who want to learn about new EmblemHealth products and Web site updates.

When: Second Wednesday of each month; 10-11 am and 2-3 pm

To register: Complete and submit an online registration form.


  • Enhanced provider manual: Now it's easy to find the details of our plans and policies. Use the drop-down menu to find chapters and sections. Or search for content by keyword, then sort results by provider type, benefit plan or managing entity. You can also subscribe to e-mail updates for the chapters or sections you reference most. We also enhanced the glossary and supplied answers to your FAQs. Experience the new provider manual.

Recent Changes to Medicaid Managed Care Coverage for 2013

Please review the following updates to Medicaid managed care coverage for 2013:

Important note: Effective April 15, 2013, HIP state sponsored programs (Medicaid, Family Health Plus and Child Health Plus) now do business under the EmblemHealth brand.

Zometa and Reclast Replaced in EmblemHealth
Injectable Drug Utilization Management Program

Due to a recent CMS J-Code edit, J3487 Zometa and J3488 Reclast have, effective July 1, 2013, been removed as covered J-Codes from EmblemHealth's Injectable Drug Utilization Management Program. Zometa and Reclast have been replaced with Q2051 zoledronic acid. More

NY Bridge Plan Administered Under
Federal Program Effective July 1, 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) has assumed administration of this program. Both EmblemHealth and HHS have notified enrolled members that, as of July 1, 2013, they are now covered by the Federal PCIP program. Certain services may require a new prior approval by the Federal PCIP, even if previously approved by EmblemHealth. There are also new rules for inpatient stays and claims submissions. More



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Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

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