EmblemHealth Partners with OrthoNet

Date Issued: 11/12/2009

(The following applies to EmblemHealth CompreHealth HMO and HIP members.)

Beginning February 1, 2010, OrthoNet LLC, on behalf of EmblemHealth, will review medical records for a sampling of submitted professional claims to ensure that the services billed reflect the services documented in the medical record and that such services are properly coded. We have executed a Business Associate Agreement with OrthoNet to ensure HIPAA compliance in all aspects of claims submission and processing.

How Does This Work?
There is no change to your current claims submission process. Claims that fit specific criteria (e.g., amount threshold, CPT code or specialty) will be selected for review. If medical documentation was not submitted with the claim, OrthoNet will send you a letter to request medical records for the claims under review. The letter will indicate the patient's name, their member ID and the date(s) of service. You may fax your documentation to OrthoNet at 1-877-499-9538.

If you receive a request for additional information, please respond as soon as possible to facilitate claims processing.

Please note: OrthoNet will not be conducting utilization reviews or making medical necessity determinations. Should you disagree with the claims payment decision, you are entitled to the appeal rights outlined in the EmblemHealth Provider Manual.

Excluded Members:
OrthoNet will not perform medical claims review for members who:

  • Are PPO/EPO members
  • Have selected a primary care physician (PCP) affiliated with St. Barnabas Hospital, Montefiore Medical Center (CMO), Health Care Partners (HCP) or Inspiris
  • Have selected a PCP with any one of the following physician group practices:
    • Queens Long Island Medical Group
    • Preferred Health Partners
    • Staten Island Physician Practice
    • Manhattan's Physician Group
    • Lenox Hill Medical Group