The Right Contacts for Claims Submissions and Utilization Management

Date Issued: 3/15/2017

As of February 1, 2017, HealthCare Partners (HCP) is now responsible for the utilization management of a new group of members. These members are identified as “HCP Cohort 2” and include a HealthCare Partners logo on the front of the member’s ID card. HealthCare Partners does not process claims for these members. EmblemHealth processes claims and handles expedited, standard and action appeals.

You need to follow HealthCare Partners’ referral and prior approval processes and use EmblemHealth’s medical policy. See the Prior Approvals section of the Care Management chapter in our provider manual.

Make sure you check the back of the member ID card to see if claims should be sent to EmblemHealth or HCP. Though HealthCare Partners is not processing claims for HCP Cohort 2 members, they continue to process claims for other members. The ID card will also tell you who to call for utilization management. The Claims Contacts section of the Directory chapter in our provider manual includes a full list of addresses of where to send paper claims.

Special Note: Member benefits have NOT changed. Members can go to ALL in-network EmblemHealth physicians, hospitals and facilities, for example, dialysis and rehabilitation centers. All health care professionals and facilities will be paid at their EmblemHealth contracted rate.