Our provider customer service telephone and Interactive Voice Response (IVR) systems are now easier and more efficient to use. Separate ID numbers are no longer required; all you need is your nine-digit tax ID number. You can also check claims status, benefits and eligibility information using the IVR system — under one option.
Please note that referral creation is no longer available via the IVR. Too few providers were using it to justify its inclusion in this new system. Instead, please use our secure provider website to create and retrieve referrals for your HMO members. To do so, clinicians must register using the Directory ID (PRIS#) for each active office, which can be found in Find a Doctor by selecting a HIP plan that you participate in and searching for yourself by name. Take a Tour to learn more about our secure provider website.
Be Prepared for the Next NYSDOH Access and Availability Survey
The sample for the next survey will include those providers previously identified as noncompliant as well as those not included in the last survey.
To prepare for the survey, please:
Update your provider profile online and make sure your telephone number, practice location(s) and provider specialty are correct.
Remind your staff that:
You are contracted to serve members in one or more of our commercial HMO, Medicaid, Family Health Plus and Child Health Plus plans. Please note: IPRO may refer to these plans as either HIP or EmblemHealth.
If you require a copy of a new memberís medical records, they should schedule an appointment, pending receipt of the records.
They should not say you are "not accepting new patients" or "are not scheduling appointments at this time" unless we have officially closed your panel.
After hours, members should have access to a "live voice" answering service or your beeper number.
Complete and Accurate Medical Record Documentation and Coding Critical to
Clear and complete clinical documentation is the foundation of every patient's health record. It significantly impacts patient care, coordination, coding, billing and compliance. It is also:
The key determinant of the quality of care a patient received
The primary tool for clinicians to communicate about a patient
Evidence that the care billed for was rendered to the patient
Data we rely on for strategic planning, internal research and identification of case, care or disease management opportunities
Accurate coding translates your clinical documentation into uniform diagnostic and procedural data sets. The better the documentation, the more we can help ensure the best outcomes for your patients — our members.
CMS Requires HIPPS and Rate Codes for Skilled Nursing Facilities and Home Health Agencies Claims —
Effective July 1, 2014
As mandated by the Centers for Medicare & Medicaid Services (CMS), beginning July 1, 2014, skilled nursing facilities and home health agencies must include all applicable Health Insurance Prospective Payment System (HIPPS) and rate codes for claims involved in Risk Adjustment Processing System (RAPS) reporting.
These codes, specifically Resource Utilization Groups (RUGs) and Home Health Resources Groups (HHRGs) identify and represent specific sets of patient characteristics (or case-mix groups). CMS uses this information for payment determination.
For EmblemHealth, this information impacts Medicare reimbursement via the RAPS reporting (CMS Encounter Data System) process. If HIPPS codes are not included in the claims submissions, the claim will be denied.
All of our instructor-led webinars and live seminars are hosted by EmblemHealth provider network staff, so any questions you have can be answered in real-time.
Select Care Instructor-Led Webinar for Specialists
Are you a specialist in our Select Care network? Plan to attend this dedicated online workshop. Topics will include: how to identify Select Care members, member benefits, how to manage our Select Care network-based plans and other valuable information.
Can't attend one of our sessions?
Then Take a Tour, explore and see what tools are available on our site.
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.
Know Your Network Participation
Your provider profile now lists your network affiliations. Keep this information handy. If the network information on the member's ID card matches your network affiliations, then you are in-network for that memberís benefit plan.
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.