UPDATE: EmblemHealth Contracts with eviCore to Expand Utilization Management

Date Issued: 1/11/2018

We previously told you that eviCore would manage Personal Care Assistants (PCA) and Consumer Directed Personal Assistance Programs (CDPAP). EmblemHealth will continue to manage these programs.

eviCore healthcare (eviCore) will begin managing the following services: durable medical equipment (DME), skilled nursing facility care, inpatient rehabilitation facility care, and long-term acute facility care (jointly referred to as Post-Acute Care (PAC) and home health care (HHC) for Health Insurance Plan of Greater New York d/b/a EmblemHealth beginning January 1, 2018, pending the approval of the New York State Department of Health.

This eviCore program change only affects Health Insurance Plan of Greater New York’s (HIP) members. EmblemHealth’s member benefits will remain the same; this is only a change regarding management and who to contact for care and coverage determinations. The transition to eviCore will not apply to:

  • Group Health Incorporated’s members
  • Members whose Managing Entity is:
    • Montefiore
    • Health Care Partners

In addition to eviCore managing DME (for the HIP members noted above), the prior approval list for DME is also changing January 1, 2018. This change applies to all members – even those who will not be managed by eviCore. (See Claims Corner).

In the upcoming weeks, eviCore will offer webinar program orientation training sessions and web portal trainings based on provider type. Providers will also be able to access recorded program trainings and materials on the eviCore website next month at evicore.com/healthplan/emblem.

In-person training invitations will be offered to high-volume DME suppliers, select hospitals and select SNF facilities based on EmblemHealth utilization trends for HIP members. Once the training schedule is finalized, eviCore will distribute training invitations and the schedule will be posted to both the eviCore website and our Seminars and Webinars web page.

Beginning January 1, 2018, (based on approval by the NY State Department of Health), prior approval requests for DME, SNF, IRF, LTAC, and HHC services for HIP members not managed by Montefiore or Health Care Partners will no longer be made on emblemhealth.com. Providers must submit all requests directly to eviCore.

If you are currently registered to use eviCore’s website to request prior approvals for our radiology programs, you will be able to use the same account to request DME services. Facilities can submit PAC prior approvals via the portal, telephone, facsimile or Allscripts. Program registration and portal details will be provided on the eviCore website or through the program training sessions.

DME suppliers, home health care, hospital and other facility discharge planners and the post-acute service providers will work directly with eviCore to transfer members to a step-down bed or facility, to arrange for care in the home, and to arrange for DME supplies that are needed by the member. All program members being discharged from the hospital requiring inpatient post-acute care or home health services will be managed by the eviCore Transitional Care Management Program for 90 days post discharge.

eviCore will be responsible for utilization management, provider customer service issues, and grievances and appeals for all members except Medicare members. EmblemHealth will continue to provide customer service to all members and will continue to address grievances and appeals for Medicare members. eviCore will credential those organizations that contract directly with them.

If you have any questions, please call eviCore at 866-417-2345.