Clinical Corner

Clinical Corner is a resource for practice guidance related to the treatment of acute, chronic and behavioral health issues as well as the medical appropriateness of specific intervention. Click on any subject of interest to access information on that topic.

Looking for information on claims? Visit Claims Corner to find updated information on claims policy, best practices for coding your claims, regulatory-driven payment methodology changes and other useful claims-related tips.

View Clinical Practice Guidelines, evidence-based recommendations to assist practitioners in determining what is covered in medical care under our health benefit plans. Providers will be notified of changes to the Clinical Practice Guidelines in the quarterly provider newsletter News&Notes and in the eNewsFlash. We recommend that network providers check this site monthly to stay current with any updates that are made.

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Drug Safety Communications for Q1 2017

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Drug Safety Communications for Q2 & Q3 of 2017

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Information on EmblemHealth’s Injectable Drug Utilization Management Program. The page includes links to guides and forms you can download.
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View EmblemHealth's Medical Policies.
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A comprehensive listing of medical technologies reviewed by the Medical Policy Subcommittee for coverage consideration. See the Medical Technologies Database for 2013.
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The EmblemHealth Commercial and Medicare formularies are compilations of brand and generic pharmaceuticals that have been identified as providing optimal results for plan members while controlling the cost of drug therapy. These formularies are updated regularly through formulary updates.
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EviCore is our vendor for the management of radiology and cardiac imaging procedures. EviCore works to improve utilization and enhance quality by integrating administrative management of patient-centered care.

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2016 Primary Care Physician incentive program for fee-for-service and ACPNY providers.

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2017 EmblemHealth
ePASS® Program Underway

The EmblemHealth ePASS® program kicked off March 1, 2017 and runs through December 31, 2017.

Managed by our partner, Inovalon, ePASS® is a web-based tool that supports improvements in documentation, quality and risk score accuracy. The ePASS® program promotes follow-up care for our Medicare HMO members and Medicaid members. These members may have undiagnosed conditions or their treatment is not recorded in their medical chart and EmblemHealth’s claims tracking system.

We want you to be a part of the ePASS® program and we’ll reward you for your efforts. By submitting a claim to EmblemHealth and completing a compliant medical SOAP note in ePASS® you can receive:

  • $150 for each Medicare member
  • $40 for each Medicaid member

Register and submit your assessments via ePASS.

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

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EmblemHealth partners with Express Scripts to manage electronic prescriptions for our members.

E-prescribing is convenient, fast and secure and is mandated by the New York State Department of Health.

It helps you as the provider by eliminating the need to handwrite most prescriptions. It also reduces paperwork, faxes and follow-up phone calls. For more information about e-prescribing, contact Express Scripts at:

Phone: 800-411-1665