VOLUME 2 | ISSUE 7  •  AUGUST 2016


Help Your Medicaid 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). Recipients must be proactive in renewing. Please remind them to call their County DSS office if their renewal application does not arrive.

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 With The Medicaid Re-enrollment Process
Regardless of where your Medicaid patients originally enrolled, if they have questions about the renewal process or want help in completing the renewal application, they may call us at 1-888-432-8026. Members may also be directed to their nearest Neighborhood Care locations where our staff can assist them with the renewal process. (More)

Compliance Requirement: Suppression of Member EOB's for Medicaid Minors

Beginning September 1, 2016, EmblemHealth will suppress Explanation of Benefits (EOBs) for all services* for Medicaid minors (0 to under 18 years of age). (More.)

*Excludes dental and other services that members are responsible for paying.

New Legislation Limits Initial Opioid Prescribing

As of July 22, 2016, initial opioid prescribing for acute pain is limited to a seven day supply to further reduce overprescribing of opioid medications, per New York State Public Health Law Section 3331, 5. (b), (c). This rule shall not include prescribing for chronic pain, pain being treated as a part of cancer care, hospice or other end-of-life care, or pain being treated as part of palliative care practices. Additional information on opioids and this legislation can be found at the Bureau of Narcotic Enforcement.

Review Our Access and Availability Standards Now

The NYSDOH requires that health plans survey their clinicians to ensure appropriate appointment availability and after-hours access for members. EmblemHealth has established appointment availability standards with which all contracted physicians are expected to adhere. The Access and Availability Standards are located in the Provider Manual at emblemhealth.com.

Prime Network Expanding To Cover
Tri-State Region

Our Prime Network, available to Commercial HMO/POS members, is growing to support City of New York and other large groups' employees who live in or near New Jersey and Connecticut. Access to NJ providers is now in place via EmblemHealth's partner QualCare. CT access is slated for January 1, 2017 via EmblemHealth's subsidiary ConnectiCare.

Recent Tier Change to Our Medicare Formulary

As of July 1, 2016, atorvastatin (generic for Lipitor®), losartan (generic for Cozaar®) and alendronate (generic for Fosamax®) were assigned to the lowest cost sharing tier on the EmblemHealth Medicare Formulary.

   Striving for Five

EmblemHealth continues to partner with the provider community to continuously improve our members' quality of care and the
overall patient experience.

How You and Your Staff Can Enhance the
Patient Experience

Keep a few appointments open for patients that need same day care. This is called "Open-Access" scheduling and has been shown to decrease the patient no-show rate at practices that implement it.

When patients visit their physicians' offices, they want a
positive experience as well as a good relationship. Effective communication can have a positive impact on patient satisfaction, resulting in greater patient compliance, increased patient safety and better clinical outcomes.

View our guide on How You and Your Staff Can Improve the Patient Experience that includes a list of all our recommendations and will assist you in creating a valuable experience for your patients.

EDI Transactions

Claims Corner

EmblemHealth Preventive Care/Screening Services Coverage

Modifier 25 must be appended to HCPCS codes G0442 – G0447 when reported with an unrelated Evaluation and Management (E/M) service, in accordance with National Correct Coding Initiatives (NCCI) policies. View the frequency limits.

Correct Reporting of Neuromuscular Junction Testing
CPT Code 95937

Use CPT Code 95937 for neuromuscular junction testing when repetitive stimulation studies are used to identify and differentiate known or suspected disorders of the NMJ, such as myasthenia gravis or myasthenic syndromes as well as botulinum toxicity. Do not use for train-of-four (TOF) monitoring.

New ClaimsXten Edits — Effective September 2016

EmblemHealth recently added new billing and reimbursement edits for all EmblemHealth benefit plans, both in- and out-of-network. The edits reflect recent updates to the ClaimsXten® software utilized by EmblemHealth.

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.

Medical Technologies Database 2016


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




The medical policies listed below have CPT/ICD code changes. Open and scroll through each policy to view the new codes.


Religion is Key in Cultural Competency

EmblemHealth is pleased to offer The Medical Manual for Religio-Cultural Competency. It provides practical information to help practitioners understand how a patient's medical decisions can be influenced by their religious observances and is the most comprehensive guide to religion and health care available. Sign on to the secure provider site to get a FREE copy of The Medical Manual.



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.

Due October 31, 2016

Complete the 2016 EmblemHealth Special Needs Plan (SNP) Model of Care (MOC) Training with the user ID/PIN that was recently sent to you via fax or email. 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 SNP MOC Training for each of the Dual Eligible SNPs in which they participate.

Breastfeeding Grand Rounds (BFGR)

BFGR is a free, annual webcast sponsored by the University at Albany School of Public Health in partnership with the NYSDOH to provide continuing education for healthcare professionals on current breastfeeding health issues with both clinical and public health significance. This year's webcast, Breastfeeding Grand Rounds: Building a Continuum of Care to Support Exclusive Breastfeeding in New York State will soon be available on demand.

Know Your Network Participation

Your provider profile lists your network affiliations. To view it, please login to your Provider/Practice Profile on our secure provider portal at emblemhealth.com. 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.

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.


EmblemHealth Neighborhood Care

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


  • Harlem
    215 W 125th St., New York, NY 10027
  • Cambria Heights
    206-20 Linden Blvd.,
    Cambria Heights, NY 11411
  • Chinatown
    87 Bowery, New York, NY 10002
  • Crown Heights
    546 Eastern Parkway,
    Brooklyn, New York 11225

Hours for ALL locations:
Mon - Fri: 10 am - 6:30 pm
Sat: 10 am - 3:30 pm




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Coverage underwritten by Group Health Incorporated (GHI) and HIP Health Plan of New York (HIP).

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