EmblemHealth Joins the NY State of Health Marketplace With Select Care

As part of the Patient Protection and Affordable Care Act, New York State has established New York State of Health: The Official Health Plan Marketplace. The Marketplace will provide uninsured and underinsured individuals and families an online place to compare insurance plans and find the plan that best suits their needs and budgets. Federal financial assistance in the form of tax credits and subsidies will be available to qualifying individuals to help make the plans more affordable. Open enrollment begins on October 1, 2013 with coverage effective January 1, 2014.

Please direct any of your patients who may be eligible for coverage to the Marketplace at to obtain more information and to purchase a plan. Your patients can also get helpful information about the Marketplace from EmblemHealth's Health Reform Web site at

On the Marketplace, EmblemHealth will offer the following Select Care products in the five boroughs of New York City and Nassau, Orange, Rockland, Suffolk and Westchester counties.

  • Select Care Basic
  • Select Care Bronze
  • Select Care Silver
  • Select Care Gold
  • Select Care Platinum

These products will use the Select Care network, which includes approximately 12,000 doctors and other health care providers as well as leading hospitals. As a participating provider, you may have received a mailing earlier this year inviting you to join the Select Care network. This network is a subset of our larger HMO network and has fewer providers; as such recruitment for this network is currently closed. (More)

Note: Beginning January 1, 2014, additional plans using the Select Care network will also be offered off the Marketplace for individuals and small groups; check back for updates.

Claims Corner

Twenty Percent Cost-Sharing for Part B Drugs in Outpatient Hospitals and Facilities

Beginning January 1, 2014, Medicare members will be responsible for paying 20 percent cost sharing for all Part B drugs administered in an outpatient hospital or facility setting as well as in a provider office. This change does not apply to Flu and Pneumonia vaccines. (More)

Use the EPO/PPO Corrected Claim form for Resubmission of GHI EPO/PPO Paper Claims.

Beginning September 1, 2013, resubmissions of corrected GHI EPO/PPO paper claims must include the EPO/PPO Corrected Professional Paper Claim form. Corrected GHI EPO/PPO paper claims without this form will be treated as a new claim submission and denied as a duplicate.

Instructions for filling out the form and submitting it with the
corrected claim:

  1. Use a separate EPO/PPO Corrected Professional Paper Claim form for each corrected claim.

Upcoming Provider Forums at EmblemHealth Neighborhood Care

Register for a Provider Forum to learn how to get the most benefit from our online tools and provider resources at

Contact Larissa Swanberg-Obadia at to register and for more information.

  • EmblemHealth Neighborhood Care — Harlem
    215 West 125th Street
    New York, NY 10027
    September 27, 2013  10 am - noon
    November 20, 2013    2 - 4 pm
  • Melville
    395 North Service Road
    Lower Level Conference Center
    October 2, 2013         9 am - noon
    November 15, 2013   9 am - noon
  • Staten Island
    Ocean View Room
    The Vanderbilty and South Fin
    at South Beach
    300 Father Capdanno Boulevard
    October 4, 2013         9 am - noon
  • EmblemHealth Neighborhood Care — Cambria Heights
    206-20 Linden Boulevard
    Cambria Heights, NY 11411
    November 6, 2013       9-11 am

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.



Review your information now to ensure you are correctly listed in our EmblemHealth directories. If any of your information has changed or is inaccurate, just follow our simple instructions to update your profile online. Can't update your information online? Fax your changes to our Provider Modifications team at 1-877-889-9061.

  1. Provide the original claim number. You can find this number on your Explanation of Benefits. You may also access it by signing in to our secure Web site at Select "Claims/Checks" and complete the requested information to view the claim in question.
  2. Check the box that corresponds to the claim information you need to correct and make the correction.
  3. Attach the updated CMS-1500 claim form to the EPO/PPO Corrected Professional Paper Claim form.
  4. Mail both forms to the PO Box that corresponds to your correction. If more than one piece of information must be corrected on the claim, send the form to the address for the most important information. Our Claims department will forward to the appropriate resource for processing.

Note: Corrections to a claim should only be submitted if the original claim information is incorrect or incomplete. Practitioners may not use a corrected claim in place of the formal grievance or appeal process.

Be Proactive: Document and Code Your Patient's Health Status Annually

It's important to keep your patients health status documented and up to date, so don't forget to document these conditions and procedures in your patients' records at least once a year:

  • Active status codes (e.g., amputation, ostomies, kidney transplant)
  • Chronic conditions (e.g., CHF, COPD, diabetes)
  • Conditions that affect activities of daily living (ADLs)
  • A previous health issue that may impact a patient's health (e.g., an old Myocardial Infarction)
  • All illnesses that require medication

Accurate and complete medical records help support your patients' continued good health — and may increase your practice's reimbursements as well.

Two New Approved Radiology Codes for Urologists — Effective September 1, 2013

Effective immediately, the following two radiology codes have been approved for urologists, as part of the Self-Referral Payment Policy. These procedure codes do not require additional accreditation.

  • CPT 74455 — Urethrocystography, voicing, radiological supervision and interpretation
  • CPT 76775 — Ultrasound, retroperitoneal, real time with image documentation; limited

EmblemHealth Neighborhood Care — Community Events


Here are a few of our September class offerings:

Cambria Heights

  • Stork's Nest Prenatal Education Curriculum
    Tuesday, September 24 and Thursday, September 26           5:45 – 7 pm
    Stork's Nest coordinators and speakers learn the basics of giving a prenatal class to community members.


  • A Life Saved: Organ Donation
    Thursday, September 26           5:30 – 6:30 pm
    Stork's Nest coordinators and speakers learn the basics of giving a prenatal class to community members.

Come hear the facts of organ and tissue donation and some inspiring real life stories.
Please RSVP: 1-347-978-5754 or 1-646-291-4454

For a full calendar of events:

Visit for more information on all that EmblemHealth Neighborhood Care has to offer you and your patients.


©2013 EmblemHealth. All Rights Reserved.

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.