VOLUME 2 | ISSUE 4  •  MAY 2016


Know Your Networks — Be Ready for the
NYSDOH Plan Participation Audit

On behalf of the NYSDOH, IPRO may contact you shortly to verify your directory information and participation in our networks. This audit is conducted on a yearly basis and includes Primary Care and Obstetrics and Gynecology practitioners. (More)

  • Prepare your office for the NYSDOH call.
    To confirm the accuracy of your information in our online directory, please verify that the practice details under each plan are correct on our website, particularly your telephone number, practice locations, provider specialty and hospital affiliations.
  • Ensure your staff is familiar with the networks you participate in.
    Once you have confirmed the accuracy of your practice information make sure each staff member that answers the phone has fast access to a list of the Networks with which your practice participates.

Access to Care — Patient Care Options When You Are Not Available

As a Primary Care Practitioner we know you are the best care option for your patients. However, members sometimes need care after your regular office hours. When this happens, make sure your patients are aware of the alternate types of care that are available.

  • 24-Hour Nurse Line.
    Members speak with an experienced, licensed nurse anytime to access clinical support for everyday health issues and questions that can save an unnecessary trip to the doctor or emergency room. Members can call 1-877-444-7988 for confidential, one-on-one health counseling and accurate information to help them make informed health care decisions.
  • Retail Health Clinics.
    Quick and convenient health care in retail stores and pharmacies for common conditions like sore throats, sprains, strains and colds.
  • Urgent Care Center (UCC).
    Obtain care for non-life-threatening injuries and illnesses like minor fractures, the flu and infections, especially after hours or on weekends.

Members should be directed to call 911 or go to the nearest emergency room when experiencing a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person's bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

Striving for Five

Earn an Incentive for the Quality Care You Provide
Primary Care Physician Incentive Award Program

EmblemHealth is committed to the health of our members and recognizes the quality of care you provide. Accordingly, we are introducing the Primary Care Physician (PCP) Incentive Award Program. Program details can be found in our Provider Manual.

New Benefit Plan Design for CNY Employees Starts July 1, 2016

Beginning on July 1, 2016, coverage for City of New York Employees and Non-Medicare Eligible Retirees will include a tiered cost-sharing option. The new benefit plan designs include a PPO Plan that utilizes the CBP Network and an HMO option that utilizes the Prime Network; the Networks offered to our members will not change. The new benefit design will allow members to enjoy reduced copayments when they obtain care from certain participating provider groups. The new benefit plan design was developed jointly with City of New York benefit leadership and constructed to offer members interested in a lower copayment an option to reduce their out of pocket expenses at the time they receive care. At the present time, we are not adding additional physicians/physician groups to the $0 copayment option. (More)

Claims Corner

ICD 10 Coding Guidance for ACA Mandated Preventive Care/Screening Services

Follow these coding guidelines and instructions for ACA mandated preventive/ screening care services to ensure appropriate processing and payment:

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.

Recent changes in the CPT/ICD diagnosis coding

The medical policies listed below have undergone recent changes in the CPT/ICD diagnosis coding. To learn more about these changes select the links below. Policy narratives remain unchanged.

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

G0475 — New Covered 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.

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



Religion is Key in Cultural Competency
Properly addressing religion is a key element of providing patient-centered care and improving health outcomes and patient and family satisfaction. The Medical Manual for Religio-Cultural Competency is the most comprehensive guide to religion and health care available. It provides practical information to help practitioners understand how a patient’s medical decisions can be influenced by their religious observances. EmblemHealth is pleased to offer this first-of-its-kind publication at no cost to our network practitioners. 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.

Identity Theft:
Learn How to Protect Yourself

In this three-part video interview, Dr. Shantanu Agrawal, Director of the Centers for Medicare & Medicaid Services’ (CMS) Center for Program Integrity (CPI), discusses medical identity theft and its impact on healthcare providers. Dr. Agrawal provides actionable advice to help providers protect themselves and report suspected identity theft. He also discusses the role Medicare Parts C and D health plans play and the initiatives CMS has undertaken to address this issue.

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 June 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.


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 NEW LOCATION
    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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