VOLUME 2 | ISSUE 3  •  APRIL 2016


Claims Corner

Correct Use Promotes Accurate Claim Payments

When filing claims, remember to use the correct taxonomy codes that represent the specific specialty rendering services and always include all diagnosis codes on your claims.

Billing for Substitute Physician Services

Here's how to ensure your claims for a Substitute Practitioners service are documented correctly:

  • When billing for a service provided by a Substitute Practitioner physician, the modifier Q5 or Q6 must follow the procedure code in Block 24D for services provided by the Substitute Practitioner.
  • Claims that include services provided by a Substitute Practitioner must include the credentialed provider's billing name, address and national provider identifier (NPI) in Block 33 of the claim form.
  • The name and mailing address of the Substitute Practitioner must be documented in Block 19, not Block 33.

Please Note:

Substitute Practitioners are not required to enroll with the health plan and should not bill the health plan directly. (More)

NYS Medicaid Expansion of Coverage of Group A Streptococcus Testing

Effective April 1, 2016, Medicaid Managed Care (MMC) reimburses practitioners for Group A Streptococcus testing (CPT code 87651) when performed in a practitioner's Office (POS 11). (More)

New Preventive Service for HIV Screening

Effective for claims with dates of service on or after April 13, 2015, new HCPCS code G0475 (HIV antigen/antibody, combination assay, screening) will be recognized as a new covered service for HIV screening. This code has been added to the Provider In Office Lab list.

Striving for Five

Encourage your patients to complete the
annual CAHPS® survey

The annual Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey is currently being sent in a yellow envelope to randomly-selected members; it asks to rate their satisfaction with their doctors and their health plan. The survey also allows us to compare our performance with that of other health plans. This is a great opportunity to review your practice protocols to ensure you are doing all you can to maintain and improve patient satisfaction. As a reminder, providers and their staff should not assist members in completing the survey or influence their responses.

Coming Soon . . . .

New Benefit Plan Design for CNY Employees

Beginning on July 1, 2016, coverage for City of New York Employees and Non-Medicare Eligible Retirees will include a tiered cost-sharing option for both the Comprehensive Benefits Plan (CBP) and HIP HMO Prime Network members. More information will be shared soon.

SelectCare Network Now Includes CityMD

CityMD is now available to Exchange members to treat common illnesses and minor injuries. We encourage you to remind our members to seek care at network urgent care centers, walk-in medical clinics, retail clinics and the toll-free 24-hour Nurse Advice Line at 1-877-444-7988 for minor ailments when their PCP is not available. Make it part of your care plan to educate members on how to seek care when you are not available.

Behavioral Health Screening Tools for PCPs

We strongly encourage our PCPs to screen members for depression, anxiety and substance abuse using these free and easy-to-use tools because early detection and intervention can have a significant impact on their health outcomes and quality of life.

HARP Expansion

On July 1, 2016, enrollment for EmblemHealth Enhanced Care Plus (aka, Health and Recovery Plan [HARP]) begins in Nassau, Suffolk and Westchester Counties. HARP became effective on October 1, 2015 in the five boroughs of New York City.

EDI Transactions

Help Your Patients Keep Their Coverage

Remind patients to renew their Medicaid eligibility. Several months before coverage ends, Medicaid recipients will receive a renewal package from their local Department of Social Services (DSS). If the renewal application does not arrive, recipients must call the DSS at one of the following numbers to request a copy.


New York City Human
Resources Adminisration (HRA)


Nassau County DSS


Suffolk County DSS


Westchester County DDS


Medicaid recipients who enrolled through the NY State of Health Marketplace must recertify through the Marketplace. This can be done by phone: 1-855-355-5777 (TTY: 1-800-662-1220) or online at nystateofhealth.ny.gov.

EmblemHealth Can Help
Our Facilitated Enrollment staff is here to assist. If your Medicaid patients have questions about the renewal process or want help in completing the renewal application, they can call us at 1-888-432-8026.

Medical Technologies Database — Updates

The Medical Technologies Database 2016 contains a comprehensive listing of medical technologies reviewed by the Medical Policy Subcommittee for coverage consideration.

Medical Guideline Updates and Additions


Code Changes:



Revision & Title Change:


Monthly Instructor-Led Webinars

For in-depth information about our Networks, benefit plans, web-based tools and resources, join us for one of our monthly live Webinars.

Offered the second Wednesday of each month, at 10 am and 2 pm, this informational session shows you how to get the most value from our website.

All instructor-led webinars are hosted by EmblemHealth provider network staff who can answer questions in real time. Space is limited, so register early.

Register today.

Coming Soon:
Required SNP MOC Training

Each year, as mandated by the Centers for Medicare & Medicaid Services (CMS), all providers in the Medicare Choice PPO Network and the VIP Prime Network are required to complete the Special Needs Plan (SNP) Model of Care (MOC) Training for each of the Dual Eligible SNPs in which they participate. In May 2016, you will receive an ID/PIN number to take this online training. Providers without computers may request a printed version and attestation of completion to return to us for tracking and reporting to CMS.

Can't update your information online? Fax your 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.

Know Your Network Participation

Your provider profile on emblemhealth.com lists your network affiliations. If the network information on the member's ID card matches your network affiliations, then you are in-network for that member's benefit plan. See the Provider Networks and Member Benefit Plans chapter of the EmblemHealth Provider Manual for a listing of all networks and plans.

Help Your Patients Stay Fit

EmblemHealth has health and wellness programs, and tools and resources to help members stay fit and enhance their quality of life. EmblemHealth members have access to Healthy Discounts at no additional cost. Participating vendors offer discounts for health club memberships, acupuncture, massage therapy and nutrition counseling, weight loss services, hearing and vision care, vitamins and supplements, and other comprehensive health care services and products. For more about these services, visit emblemhealth.com/Health-and-Wellness/Stay-Healthy/Healthy-Discounts.aspx.

Do More On the Go!

Our myEmblemHealth mobile app provides useful benefit and plan information for members, right at their fingertips:

•  Search for a doctor or hospital

•  See copay, benefit and claims

•  Access their ID card

•  Pay their bill

•  View their physician (PCP)

Easy access — anytime, anywhere! Encourage your patients to download it today.

Available on all iOS and Android devices.


Visit EHNC for a list of community events and information on all that EmblemHealth Neighborhood Care has to offer.


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    Brooklyn, New York 11225

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