2023-2024 Annual Provider Notification

Group of happy healthcare providers looking at a computer in office

See our 2024 Network and Benefit Plans.

View 2024 Summary

What to Expect for 2024 & 2023 Year in Review

Please review and share this notice and the following materials with your clinicians and staff. This streamlined recap of 2023 guidance and what you’ll need to know for 2024 will help you care for your patients and help us work better together.

We have made some significant improvements to our provider portal to help you get faster preauthorization determinations.

As always, visit our Provider Manual for guidance and reference on regulatory, policy, and accreditation requirements (such as provider rights, member rights and responsibilities, availability of criteria, and pharmacy procedures). Here are some of the most visited sections within the Provider Manual:

Credentialing Information | Member Rights and Responsibilities| Pharmaceutical Procedures

Care Management | Behavioral Health Services

*Members assigned to HealthCare Partners and SOMOS will continue to follow their administrative processes and will need to submit Emergency Room admission/newborn notifications directly to them. Our vendor partners who manage our Utilization Management Programs will continue to use their own websites and provider portals for transactions.

Key Things To Know

Doctor and nurse talking in hospital and looking at document

2024 Network and Benefit Plans

See the changes we are making to our 2024 offerings.

patient and doctor smiling and looking at notes

Patient Experience, Access to Care, and Quality Improvement

We value our members’ experience with us and with you, our contracted providers.

pharmacist talking to customer about his prescription.

2024 Pharmacy Formularies

Visit EmblemHealth’s 2024 Formulary Updates webpage.

doctor smiling and using laptop computer on work table.

Learning Online: Training and Educational Opportunities

Required and recommended learning opportunities for Providers.

At EmblemHealth, we value our members’ experience with us and with you, our contracted providers. A member’s experience often begins with their use of our provider directories. We ask you to keep your listings current. Once members have found the right provider, their next experience is appointment scheduling.

Members expect their providers to schedule timely appointments and to know whether services need referrals or preauthorizations.

Members expect to be treated with dignity, in a  culturally competent manner, free from discrimination, and to have their rights honored. We also expect our members to respect you and to honor their responsibilities. 

Health care professionals have the greatest impact on clinical outcomes. Those who follow established guidelines and best practices are successfully increasing quality measure scores and patient satisfaction. The following links include information to help you meet members’ expectations and outline the way we measure clinical outcomes.

Easy Access to Key Resources  

Continuous Quality Improvement 
We have adopted the Institute for Healthcare Improvement (IHI) and the Centers for Medicare & Medicaid Services (CMS) Triple Aim for Healthcare Improvement. We strive to simultaneously improve the health status of our members, improve each member’s experience of care, and reduce the per capita cost of health care.

See our Provider Manual and new Quality Improvement page to learn more about our Quality Improvement Program.  

Health Care Transparency in Cost and Quality Information
Effective Dec. 27, 2020, the Consolidated Appropriations Act, 2021 includes provisions designed to expand transparency in cost and quality information for health care consumers and employer groups. See the EmblemHealth Provider Manual for the impacts to our provider agreements and Federal Employees Health Benefits (FEHB) member costs for items or services.

New York Law Prohibits Certain Terms in Health Plan Provider Contracts
Effective July 1, 2023, all participating agreements were updated to eliminate most-favored nations provisions as well as any prohibitions on the disclosure of:

Actual claim costs.
Price or quality information that must be disclosed under federal law, including the allowed amount, negotiated rates or discounts, or any other claim-related financial obligations, including, but not limited to, patient cost-sharing or any public compilation of reimbursement data such as the New York All Payer Database.

2024 Formulary Updates
To see announcements of formulary changes, see EmblemHealth’s 2024 Formulary Updates web page. To determine whether a specific drug is covered by a member’s health plan, use the applicable formulary search:

Our Find a Network Pharmacy tools can help you and your members find a nearby participating pharmacy.

Updated Pharmacy Preauthorization Lists
The Home Infusion Therapy Drug Preauthorization List and the Pharmacy Medical Preauthorization Lists for EmblemHealth and ConnectiCare were updated as shown in their revision histories.

Montefiore CMO Is No longer a Managing Entity
Effective April 1, 2023, the Montefiore Care Management Organization (CMO) is no longer the managing entity or performs pharmacy utilization management for the following members:

EmblemHealth Enhanced Care (Medicaid)
Enhanced Care Plus (HARP)
Child Health Plus (CHPlus)
HMO Prime
HMO Access I
HMO Plus
HMO Preferred

Medicaid Pharmacy Benefit Transition
Starting April 1, 2023, EmblemHealth’s Enhanced Care (Medicaid) and Enhanced Care Plus (HARP) members will have their pharmacy benefits transitioned from EmblemHealth to NYRx, the New York State (NYS) Medicaid Pharmacy program. Information regarding the pharmacy benefit transition is in the October 2022 and January 2023 Special Edition of the Medicaid Update.

New Claim Process for Medicare Part D Vaccine Billing
May 16, 2023, Medicare Part D vaccine claims should be submitted to TransactRx at: transactrx.com/physician-vaccine-billing. The Part D Vaccine Billing Guidelines (Medicare) Reimbursement Policy that was in effect for ConnectiCare was adopted by EmblemHealth.

Note: Neither company will reimburse claims for Part D vaccines administered in the physician’s office and submitted under the Part B medical benefit.

Rethinking Concurrent Use of GLP-1 and DPP-4 Agents
The American Diabetes Association (ADA) and the American Association of Clinical Endocrinology (AACE) recommend glucagon-like peptide 1 receptor agonists (GLP-1) as an add-on therapy to oral agents and in combination with insulin for the treatment of diabetes. Current guidelines by the ADA and AACE, as well as the Food & Drug Administration (FDA), do NOT support combination therapy of GLP-1 and dipeptidyl peptidase 4 inhibitors (DPP-4) due to lack of added clinical benefit. See full details DRUG ALERT – Concurrent Use of GLP-1 and DPP-4 Agents.

Biosimilars: Are They the Same Quality?
The Food & Drug Administration (FDA) encourages use of this infographic to talk with your patients about biologics and biosimilars. The FDA also offers free accredited continuing education courses for health care providers. Use the links below to take these classes.

Infusion Therapy
Reminder: We have site of service rules for EmblemHealth’s adult commercial members when receiving infusion therapy. Where they get their care can impact their out-of-pocket costs. For full details, please see the Site of Service Medical Policy – Infusions and Injectables.

If you have a patient who needs infusion therapy, please see if they can take advantage of the concierge experience we created with New York Cancer & Blood Specialists (NYCBS).

For help finding an optimal infusion setting for your patient, email us at homeinfusionteam@emblemhealth.com.

Resources to Help Improve Medication Adherence
Continued adherence to a prescription drug regimen is essential to achieve the desired therapeutic outcome for your patients. There are several resources available in different languages on both EmblemHealth’s and ConnectiCare’s medication adherence web pages that can be shared with your patients.

The Learning Online section of our provider website is filled with required and recommended learning opportunities.

Here is a sampling of what you can find there:

Required Training for EmblemHealth Practitioners, Providers, and Vendors – Special Needs Plan (SNP) Model of Care (MOC) training for providers in the VIP Bold Network and Network Access Network.
Required Medicare Training on Fraud, Waste, and Abuse.
Cultural Competency Continuing Education and Resources.
Health Literacy.
Free Continuing Medical Education (CME) Activities Sponsored by Pri-Med.
HIV/AIDS Education.
LGBTQ+ Education.

Free Veradigm Webinars for Patient Management and ICD-10 Coding
Veradigm offers free webinars for patient management and ICD-10 coding training. To register, go to Online Learning > Veradigm Webinars to scan topics and dates. Click the Registration button at the bottom, then the Public Event List link and search by the webinar date or title of interest.

If you have any questions, or you would like to set up a private training session for your practice, please email Veradigm at ProviderEngagement@Veradigm.com or call Veradigm’s Customer Support team at 410-928-4218, option 7, available 8 a.m. to 8 p.m., Monday through Friday.

You can also learn more about the risk adjustment program here.

HIV/AIDS and Sexually Transmitted Diseases
Pri-Med offers HIV/AIDS and sexually transmitted disease (STD) education courses such as “Advancing the Dialogue: What PCPs Need to Know about PrEP.” To locate these courses, search for “HIV” to find them. You can manage your learning, track credits online, and complete activities at your own pace.

The New York State Department of Health, AIDS Institute has lead responsibility for coordinating state programs, services, and activities relating to HIV/AIDS, STDs, and hepatitis C. For information on programs, initiatives, and services, visit the AIDS Institute for additional training and resources to help your patients.

To refer a patient to the EmblemHealth HIV Case Management program, please call or have the member call 800-447-0768.

doctor writing and smiling outside with trees

Clinical Corner: Updates & Announcements

Summary of key items posted this last year and changes for 2024.

happy medical team standing and meeting with laptop computer

Clinical Corner: Programs, Resources & Requirements

See how we can support your care for our members.

health care providers talking and looking at clipboard and tablet

Clinical Corner: Policy & Guideline Updates

See updates made to our Preauthorization Lists, Medical Policies, and Clinical Practice Guidelines.

psychotherapist using digital tablet and talking to patient at clinic.

Behavioral Health: Mental Health & Substance Abuse

We provide options that can help you manage mental health and substance abuse.

The Clinical Corner section of the EmblemHealth provider website is part of the EmblemHealth Provider Manual and houses Administrative Guidelines described in our participation agreements. This is where you will find:

Be sure to regularly check the Clinical Corner for the latest updates.

Here is a summary of the key updates posted this past year and those anticipated for 2024.

MD Perspectives
See what our medical directors are sharing about clinical considerations, population health, mental health matters, and resources to help you.

Enhanced Preauthorization Request Transactions Accelerate Care
This year we implemented enhanced provider portal preauthorization transaction screens called “MCG” screens to:

Share needed clinical information up front.
Receive faster responses to your requests when you use the Submit Request button on the new screen.

See how using our provider portal accelerates care by simplifying preauthorization and clinical reviews. Also see the updated provider portal training guides for instructions on using the new screens.

If you need help setting up a portal account, please use the new Provider Portal Registration Form: EmblemHealth | ConnectiCare.

Earn Incentives for Colorectal Cancer & Other Screenings
There is still time for many primary care providers (PCPs) to earn incentives for colorectal cancer and other key screenings for qualifying members. See the Quality Incentive Program 2023 on our Quality Improvement page.

Palladian Health Leaving Network & Ending UM and Claims Management
Effective Dec. 31, 2023, Palladian Health (Palladian) and its associated providers will no longer participate in EmblemHealth’s networks. Additionally, Palladian will no longer perform utilization management and claims payment for EmblemHealth members after the termination date.

Preauthorization requests and claims submitted to Palladian for dates of service prior to the termination date will be handled by Palladian. For dates of service beginning Jan. 1, 2024, the provision of physical therapy, occupational therapy, and chiropractic care for EmblemHealth members will transition from Palladian to EmblemHealth.

Preauthorizations and referrals will no longer be required. Claims for these services should be submitted to EmblemHealth or the Managing Entity as listed on the member’s ID card. Refer to the Directory chapter of our Provider Manual for Claims Contacts.

Managing Entity Change April 1, 2023
Effective April 1, 2023, the Montefiore Care Management Organization (CMO) no longer is the Managing Entity for the following members:

EmblemHealth Enhanced Care (Medicaid)
Enhanced Care Plus (HARP)
Child Health Plus (CHPlus)
HMO Prime
HMO Access I
HMO Plus
HMO Preferred

As a result, CMO no longer performs utilization management (including pharmacy), case management, claims payment, and behavioral health management services for these members.

In-home Palliative Care Services
On Jan. 1, 2023, we began offering in-home palliative care services to eligible EmblemHealth members as part of our care/case management programs. See full announcement.

Note: Aspire Health, which manages this program, will be changing its name to Carelon Health starting Jan. 1, 2024.

The Clinical Corner section of the EmblemHealth provider website is part of the EmblemHealth Provider Manual and contains the Administrative Guidelines described in our participation agreements. This is where you will find:

Be sure to regularly check the Clinical Corner for the latest updates.

MD Perspectives
See what our medical directors are sharing about clinical considerations, population health, mental health matters, and resources to help you.

Concierge Programs Give Our Providers and Members Options
Learn about the concierge programs we are creating to give our members the best health care experiences possible. Now available:

Outpatient Surgical Concierge Program in NYC
Total Joint Replacement Concierge Program
New York Cancer and Blood Specialists (NYCBS)

Care/Case Management Programs
EmblemHealth and ConnectiCare’s Care Management programs can assist providers by helping navigate our delivery systems, and coordinate care across care settings to ensure our members get the necessary treatment and resources in the right setting.

New in 2023: Palliative Care for Vulnerable Members.

To refer a member to one of our Care/Case Management programs:
EmblemHealth: See our Care/Case Management Programs page for program descriptions, ways we can support you and your patients, and program-specific contact information. If you need general assistance, you can call 800-447-0768 Monday through Friday from 9 a.m. to 5 p.m.

ConnectiCare: Call 800-390-3522 Monday, Thursday, and Friday from 8 a.m. to 4 p.m. or Tuesday and Wednesday from 8 a.m. to 7:30 p.m.

Mandatory Reporting
To ensure public safety and track conditions affecting public health, the federal government, New York state, and New York City agencies have enacted laws that must be followed by health care professionals. Our network practitioners are required to participate in government reporting procedures and adhere to all rules, regulations, and codes. For a list of government agencies with required reporting, read the Regulatory Mandatory Reporting chapter of our online Provider Manual.

Be sure to regularly check the Clinical Corner for the latest updates.

Here is a summary of the key updates posted this past year and those anticipated for 2024.

MD Perspectives
See what our medical directors are sharing about clinical considerations, population health, mental health matters, and resources to help you.

Referral Policy Updates
The “Do I need a referral?” – A Quick Guide has updated resources for 2024, including a video to help providers understand when a referral is needed. Please review so you know whether a member needs a referral to see a specialist.

Preauthorization Requirements
Visit our EmblemHealth Preauthorization Lists page to see what services require preauthorization and who is responsible for the utilization review.

EmblemHealth Preauthorization List: See Notable Changes for updates.

See revision histories for the updates to the following lists:

GHI PPO City of New York Preauthorization List
ConnectiCare Commercial Preauthorization List
ConnectiCare Medicare Preauthorization List
EmblemHealth/ConnectiCare Home Infusion Therapy Drug Preauthorization List
Pharmacy Medical Preauthorization Lists for EmblemHealth and ConnectiCare

Clinical Practice Guidelines
We encourage our providers to consult EmblemHealth’s Clinical Practice Guidelines (CPGs) for assistance in the treatment of acute, chronic (e.g., HIV), and behavioral health issues

Our Medical Policy Committee reviewed the CPGs for EmblemHealth and ConnectiCare and approved the following updates:

New CPGs:

Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease – 2023
Report Bone Health and Osteoporosis
Osteoporosis (Treatment, Screening, and Diagnosis)
Smoking and Tobacco Use, Clinical Cessation Tools

Updated CPGs:

American Family Physicians Coronary Artery Disease/Coronary Heart Disease

Removed CPGs:

Osteoporosis
Pharmacological Management of Osteoporosis in Postmenopausal Women Guideline Resources
Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Persons
Tobacco Smoking Cessation in Adults, Including Pregnant Persons: Interventions
Treating Tobacco Use and Dependence: 2008 Update

Update Medical Policy Updates
EmblemHealth’s Medical Policies are posted in the Clinical Corner. Pharmacy Medical Policies, Enterprise Pharmacy Medical Policies, and New Century Health – Medical Oncology Policies are posted on separate pages.

Below, find the revised and retired EmblemHealth medical policies that have been published in the past year. A similar list can be found in the ConnectiCare section of this annual notice regarding ConnectiCare’s Medical Policies.

Revised Medical Policies:

Autologous Chondrocyte Implantation
Bariatric Surgery
Blepharoplasty
Gender Affirming/Reassignment Surgery
Gene Expression Profiling
Gene Expression Profiling and Biomarker Testing for Breast Cancer
Glaucoma Surgery
Hyperbaric Oxygen Therapy
Infertility Services
Lyme Disease Intravenous Treatment
Orthognathic Surgery
Osteochondral Grafting
Rhinoplasty
Stereotactic Radiosurgery and Proton Beam
Therapy Vacuum-Assisted Wound Closure

Retired Medical Policies:

Acupuncture for Chronic Low Back Pain
Ambulatory Monitoring Electroencephalogram
Automatic Blood Pressure Monitor
BRCA1 and 2 Genetic/BRAC Analysis Rearrangement Testing
Capsule Endoscopy (Camera Pill)
Cryosurgery for Liver Tumors
Cryosurgical Ablation for Prostate Cancer
Cryosurgical and Radiofrequency Ablation for Renal Tumors
Doula Services – Medicaid
Fecal Microbiota Transplant (FMT) for Recurrent Clostridium Difficile Infection
gammaCore Sapphire CV for Coronavirus Disease 2019
Gene Expression Profile Testing for Multiple Myeloma
Genetic Analysis of PIK3CA Status in Tumor Cells
Genetic Counseling and Testing Genetic Testing for Colorectal Cancer/Lynch Syndrome
Genetic Testing for PTEN Hamartoma Tumor Syndrome
Home Birth Midwifery Services
Idiopathic Environmental Intolerance
Lipoprotein Subclassification Testing
Lymphedema Treatment
MyVantage™ Hereditary Comprehensive Cancer Panel
Non-Invasive Electroencephalogram
Noninvasive H pylori Testing
Noninvasive Prenatal Testing for Fetal Aneuploidy
Obstructive Sleep Apnea Diagnosis and Treatment
Outpatient Cardiac Rehabilitation
Pasteurized Donor Human Breast Milk (PDHM)
Periurethral Bulking Agents for Urinary Incontinence
Site of Service
Supervised Exercise Therapy for Symptomatic Peripheral Artery Disease
Therapeutic Shoes for Diabetics
Vitamin D Deficiency Testing (CCI Commercial)

doctor working at the hospital and holding a clipboard

Claims Corner: Policy Updates

Payment integrity, reimbursement, and administrative guidelines.

doctor working at computer in the office

Claims Corner, Part 1: Announcements & Reminders

Claims-related stories about audits, polices, and programs that you may have missed in our newsletters.

doctor smiling and looking at computer in the office

Claims Corner, Part 2: Announcements & Reminders

More claims related stories about audits, polices, and programs that you may have missed in our newsletters.

Healthcare professional holding pen with laptop and smiling

ConnectiCare in 2024 & 2023 Reminders

Many EmblemHealth and ConnectiCare plans have reciprocity.

The Claims Corner section of our provider website is part of the EmblemHealth Provider Manual and houses our Payment Integrity and Reimbursement Policies and Administrative Guidelines described in our participation agreements. Be sure to check the Claims Corner section of our provider website frequently for the latest updates. Here are the policy updates you may have missed:

New and Updated Policies
Formalized Policies
Over the past year, we have continued our efforts to consolidate and document our administrative guidelines into formal policy formats. We are doing this to:

Help you find the information you need.
Introduce a Revision History to increase transparency when an update is made. Look to revision histories for the effective dates of updates and what has changed, including codes added and/or removed from the scope of the policy.

Formalized Polices vs. New Policies
Unless a change is specifically indicated in the provider newsletter, when we say a formalized policy has been introduced, we mean that the current policy has been reformatted, but no changes were made to the way we are processing claims or the workflows you need to follow. Once a formalized policy is introduced and added to the Claims Corner, we may remove the same content from other pages on our website to avoid duplication.

New policies will introduce policies that were not previously in existence or may indicate changes to current policies or administrative guidelines. If we introduce a new policy and there are administrative guidelines posted to our website that reflect former or expiring claims payment policies or workflows, we will move the ineffective content to an online archive. That way, you will continue to have access to the rules that were in effect when older services were rendered or claims processed.

Payment Integrity Policies
The following is a list of formalized and new Payment Integrity Policies that were introduced in the past year:

Annual Fee Schedule Updates Payment Integrity Policy.
Device, Implant and Skin Substitutes (Facilities) Payment Integrity Policy.
Laboratory Benefit Management Payment Integrity Policy.

Reimbursement Policies
The following is a list of formalized and new Reimbursement Policies that were introduced in the past year:

Bundled Services Reimbursement Policy (Commercial and Medicare).
Facility Fees for E&M Services on Outpatient Facility Claims (Commercial).
Foot Care Services and Nail Debridement Reimbursement. Policy (Commercial, Medicare, and Medicaid).
HCPCS and CPT Coding Requirements for Outpatient Claims.
Part D Vaccine Billing Guidelines (Medicare) Reimbursement Policy.
Radiopharmaceuticals and Contrast Media Policy.
Split/Fragmented Billing Services Reimbursement Policy.

Updated Reimbursement Policies
The following reimbursement policies were updated. See their revision histories for effective dates and applicable changes:

Allergy Testing Immunotherapy Policy.
Coding Edits Policy.
Commercial Preventive Services List.
Corrected Claims Submission Policy.
COVID-19 Vaccine and Monoclonal Antibody Infusions Policy.
Durable Medical Equipment (DME) in Office/Non-Facility Place of Service (Commercial and Medicare).
Home Health Care Services Reimbursement Policy.

Laboratory Benefit Management (LBM) Policies:

Allergen Testing (LBM).
Biomarkers Testing for Autoimmune Rheumatic Disease (LBM) replaces the ANA/ENA Testing (LBM) Vectra Da Blood Test for Rheumatoid Arthritis (LBM) policies.
Colorectal Cancer (LBM) replaces the Preventive Screening in Adults (LBM) policy.
Diagnosis of Idiopathic Environmental Intolerance (LBM).
Diagnosis of Vaginitis including Multi-target PCR Testing (LBM).
Diagnostic Testing of Common Sexually Transmitted Infections (LBM).
Diagnostic Testing of Iron Homeostasis & Metabolism (LBM). Evaluation of Dry Eyes Testing (LBM). Flow Cytometry (LBM).
Helicobacter Pylori Testing (LBM). Hepatitis Testing replaces Hepatitis C (LBM).
HIV Genotyping and Phenotyping (LBM). Diabetes Mellitus Testing replaces Hemoglobin A1c (LBM).
Human Immunodeficiency Virus (HIV) (LBM) replaces HIV Genotyping and Phenotyping (LBM).
Immunohistochemistry (LBM).
Intracellular Micronutrient Analysis (LBM).
Lyme Disease (LBM).
Onychomycosis Testing (LBM).
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing (LBM).
Pediatric Preventive Screening (LBM).
Prescription Medication and Illicit Drug Testing in Outpatient Setting (LBM).
Preventive Screening in Adults (LBM).
Prostate-Specific Antigen (PSA) Testing (LBM).
Salivary Hormone Testing (LBM).
Testosterone Testing (LBM).
Thyroid Disease Testing (LBM).
Urinary Tumor Markers for Bladder Cancer (LBM).
Vectra DA Blood Test for Rheumatoid Arthritis (LBM).
Venous and Arterial Thrombosis Risk Testing (LBM).
Vitamin D Testing (LBM).
Laboratory/Venipuncture Reimbursement Policy.
Medicare Preventive Services List.
Modifier Reference Policy.
From/To Date Span Policy, Facility and Professional (Commercial, Medicare, and Medicaid) Reimbursement Policy.
Outpatient Diagnostic Imaging Self-Referral Payment Policy.
Unlisted Codes Policy.

See ConnectiCare In 2024 & What You May Have Missed in 2023 to see its new and updated policies.

Here are the claims-related stories about audits, policies, and programs shared in our newsletters that you may have missed:

Medical Record Requests for 2022 HHS-Risk Adjustment Data Validation Audit (HHS-RADV)
Each year, EmblemHealth and ConnectiCare are required to respond to the Department of Health & Human Services (HHS)-Risk Adjustment Data Validation Audit (HHS-RADV) of its Affordable Care Act (ACA) exchange members. If you were included in the audit sample and receive a request for medical records from our initial validation auditor, Cognisight, Inc., we ask that you respond promptly and submit the required documentation using a secure delivery method. Cognisight will provide detailed submission instructions in its communication materials. For additional detail, see our audit announcement.

Actual claim costs.
Price or quality information that must be disclosed under federal law, including the allowed amount, negotiated rates or discounts, or any other claim-related financial obligations, including, but not limited to, patient cost-sharing or any public compilation of reimbursement data such as the New York All Payer Database.

Device, Implant and Skin Substitutes (Facilities) Policy
Starting Dec. 14, 2023, EmblemHealth and ConnectiCare are enforcing the following Coding Guidelines: Device, Implant and Skin Substitutes (Facilities) Payment Integrity Policy. This policy outlines coding requirements for the billing of devices, implants, and/or skin substitutes along with their correlating procedures and offers directives for inpatient and outpatient hospital services in the correct revenue coding. The policy is based on guidelines set forth by the U.S. Food and Drug Administration (FDA) classification of products as implants.

Avoid Denials – Use Correct Member ID
When we introduced our current claims system several years ago, commercial and Medicare members were issued new member IDs starting with the letter “K” followed by 10 digits (K-ID). We have found that some providers are still using the old member IDs on their electronic transactions (e.g., 270, 276, 837).

Now that we are beyond the timely filing deadline for all possible claims containing the old member IDs, we have decommissioned our old claims systems. We have also retired and can no longer accept or use the old commercial and Medicare member IDs. This means that the K-ID must be used for these members. Otherwise, your:

Claims will be denied.
Eligibility and preauthorization transactions on our provider portal will show that the member cannot be found. Incorrect information will be returned on electronic transactions if the member cannot be found.

Updates to Self-Funded Plan Timely Filing Limits
Starting Sept. 1, 2023, providers are required to submit claims for EmblemHealth members who are part of the Local 389 Health and Welfare Fund within 90 days of the date of service. This time frame applies to new in- and out-of-network medical claims (professional, hospital, and other facility claims). See full Claims Submission – Timely Filing requirements.

Laboratory Benefit Management Program
EmblemHealth and ConnectiCare implemented a Laboratory Benefit Management (LBM) program in collaboration with Avalon Healthcare Solutions. The Laboratory Benefit Management Payment Integrity Policy details the program components, including impacted laboratory services, tests, and procedures. It also includes a section of anticipated frequently asked questions (FAQs). In addition, we have posted training guides to help you understand how this program helps us process laboratory claims with greater accuracy and consistency.

The program’s reimbursement policies are on our websites and are available for your review. If you receive a claim denial, the message will provide this website address, bit.ly/Our-RP, as a shortcut to the policies. Look for the applicable test to see why the claim was denied. It will be tagged “(LBM).” The same policies may be found on both of our sites at the following links:

EmblemHealth: Reimbursement Policies
ConnectiCare: Reimbursement Policies

To reflect the end of the COVID-19 Public Health Emergency, we replaced the COVID-19 Testing Reimbursement Policy with this new one: Coronavirus Testing in the Outpatient Setting (LBM). We also updated the Payment Integrity Policy for the Laboratory Benefit Management Program to add Coronavirus Testing in the Outpatient Setting (LBM) to the Reimbursement Policies table.

EmblemHealth Risk Adjustment Program for Primary Care Providers
Together, EmblemHealth and Pulse8™ promote risk adjustment education and gap closure efforts for our New York State of Health (NYSOH) Marketplace, Medicare HMO, and Medicaid members. See the Pulse8 Risk Adjustment frequently asked questions.

Primary care providers (PCPs) are encouraged to take advantage of these additional compensation opportunities and Pulse8’s free monthly webinars. You may use telehealth/virtual care to close gaps in care.

CPT and HCPCS Billing Guidelines
While EmblemHealth recognizes some HCPCS codes, they are not always consistent with those recognized by Medicare. Although exceptions may apply, such as for drug testing, unless otherwise specified, CPT codes should be billed even when there is a corresponding HCPCS code.

Whenever possible, convert HCPCS code(s) to the applicable CPT code(s) before you submit your claims to EmblemHealth or ConnectiCare. When a more appropriate code is required, a service may be denied, giving the provider an opportunity to submit a more appropriate code. See CPT and HCPCS Billing Guidelines.

Daily Maximum Units
EmblemHealth and ConnectiCare follow the Centers for Medicare & Medicaid Services (CMS) guidelines. We will not reimburse CPT/HCPCS codes with a Medically Unlikely Edits (MUE) value of “0” (zero). This applies to all EmblemHealth and ConnectiCare Medicare Advantage plans. For Medicare non-covered services that are covered by our Commercial plans, EmblemHealth and ConnectiCare have established Maximum Daily Frequency (MDF) exceptions. These exceptions are listed in our Daily Maximum Units reimbursement policy.

NPI & Taxonomy Codes
Sign in to your Provider/Practice Profile to make sure you have the right National Provider Identifier (NPI) and Taxonomy Code(s) on file.

No-Cost Electronic Funds Program
ECHO Health, Inc. facilitates claims payments for EmblemHealth. Through ECHO, you can, at no cost, receive direct deposits to your bank account(s) (known as electronic funds transfer (EFT)) and view or download your remittances online (known as electronic remittance advice (ERA)). Visit ECHO, click the “Click Here” button, and follow the instructions to enroll.

Many EmblemHealth and ConnectiCare members have plans that give them access to providers in both organizations. Check the 2024 Summary of Companies, Lines of Business, Networks & Benefit Plans to see which plans and networks offer reciprocity and view details on primary care provider (PCP) and referral requirements, out-of-network coverage, copays, and maximum out-of-pocket limits.

Sample EmblemHealth and ConnectiCare member ID cards may be found in the EmblemHealth Provider Manual and on ConnectiCare’s Commercial Networks and Benefit Plans page.

For changes to ConnectiCare’s benefit plans and delivery system that could affect EmblemHealth providers treating ConnectiCare members, see ConnectiCare’s Commercial Networks and Benefit Plans and Medicare Advantage Plan pages.Throughout the year, updates will be posted to ConnectiCare’s News and Updates, appear in the provider portal’s newsfeed, and shared in our Office Visit Newsletter.

New in 2024: Value Network
Starting Jan. 1, 2024, ConnectiCare will launch a new tailored network called “Value” that will be offered to commercial large group and individual members who purchase health benefit plans from ConnectiCare Insurance Company, Inc. through Access Health CT.

Our Value Network features a tailored network that is a subset of our commercial Choice Network. It may be the right solution for individuals who can choose care options within a more localized area. All Value Network providers are located in Connecticut. There is no reciprocity with EmblemHealth’s networks.

ConnectiCare member ID cards will clearly indicate whether a member has selected the Value Network. Members do not need a primary care provider (PCP) and do not need referrals to see specialists in this network.

ConnectiCare’s Medical Policy Updates
ConnectiCare’s Medical Policies are posted on the Medical Coverage Criteria page. At the top of the page, select Commercial or Medicare to see the applicable policies. Below, find the new and revised medical policies published since last year.

Revised ConnectiCare Medical Policies

Autologous Chondrocyte Implantation
Bariatric Surgery
Blepharoplasty
Gender Affirming/Reassignment Surgery
Glaucoma Surgery
Infertility Services
Lyme Disease Intravenous Treatment
Non-Invasive Electroencephalogram
Osteochondral Grafting
Orthognatic Surgery
Rhinoplasty
Vacuum-Assisted Wound Closure

Retired ConnectiCare Medical Policies

Acupuncture for Chronic Low Back Pain
Ambulatory Monitoring Electroencephalogram
Capsule Endoscopy (Camera Pill)
Cryosurgery for Liver Tumors
Cryosurgical Ablation for Prostate Cancer
Cryosurgical and Radiofrequency Ablation for Renal Tumors
Fecal Microbiota Transplant (FMT) for Recurrent Clostridium Difficile Infection
Formula and Enteral Nutrition
gammaCore Sapphire CV for Coronavirus Disease 2019
Home Health Aide Services
Idiopathic Environmental Intolerance (ConnectiCare commercial)
Lipoprotein Subclassification Testing
Lymphedema Treatment
Noninvasive Prenatal Testing for Fetal Aneuploidy
Obstructive Sleep Apnea Diagnosis and Treatment
Osteopathic Manipulative Treatment
Periurethral Bulking Agents for Urinary Incontinence
Site of Service
Vitamin D Deficiency Testing (ConnectiCare commercial)

Formalized and New ConnectiCare Payment Integrity and Reimbursement Policies
The following is a list of both formalized and new Payment Integrity Policies that we introduced in the last year for ConnectiCare:

Annual Fee Schedule Updates Payment Integrity Policy
Laboratory Benefit Management Payment Integrity Policy

The following is a list of both formalized and new Reimbursement Policies that we introduced in the last year for ConnectiCare:

Bundled Services Reimbursement Policy (commercial and Medicare)
Coding Edits
Corrected Claims Submission Policy
Foot Care Services and Nail Debridement Reimbursement Policy (commercial and Medicare)
From/To Date Span Policy, Facility and Professional
(Commercial, Medicare, and Medicaid) Reimbursement Policy
HCPCS and CPT Coding Requirements for Outpatient Claims
Maximum Frequency – Per Day (commercial and Medicare)
Radiopharmaceuticals and Contrast Media Policy
Split/Fragmented Billing Services Reimbursement Policy
Unlisted Procedure Codes Reimbursement Policy

Updated ConnectiCare Reimbursement Policies
The following Reimbursement Policies were updated. See their revision histories for effective dates and applicable changes:

Ambulatory Surgical Grouper Policy
Allergy Testing Immunotherapy Reimbursement Policy
Coding Edits
Commercial Preventive Services List
COVID-19 Vaccine and Monoclonal Antibody Infusions Policy
Durable Medical Equipment (DME) in Office / Non-Facility Place of Service (commercial and Medicare)
Home Health Care Services Policy
Laboratory/Venipuncture Policy
Modifier Reference Policy
Medicare Preventive Services List
Maximum Frequency – Per Day (commercial and Medicare)
Unlisted Procedure Codes Reimbursement Policy

Your Resources

Provider Portal

Visit frequently asked questions, videos, and user guides for assistance.

Key Portal Updates
Provider Manual

View your administrative responsibilities, contract agreements, and how to help members navigate our delivery systems.

View Provider Manual
Provider Toolkit

Guides and quick references to help with the administration of our plans.

View Toolkit
Provider Newsletter

The Office Visit is our monthly newsletter. See editions you may have missed.

View Newsletters
MD Perspectives

Hear from our Medical Directors on timely health topics.

View Blogs
Member Materials

Find materials you can give your members in support of your care plans.

See Member Materials
Neighborhood Care

Let us help you help our members. See how we can support you.

Learn more

Our provider portal is designed to be simple and intuitive. Should you need help, see these frequently asked questions, videos, and user guides to help you, step-by-step, through each transaction. If you need help setting up an account and do not know who in your organization has been designated to manage user accounts, you can fill out the Provider Portal Registration Form and we will assist you.

What’s new in 2023
We have been rolling out changes to the utilization management (UM) transactions to make it easier for you to submit documents using the portal and to get faster decisions for your preauthorization requests, concurrent reviews, and discharge plans (UM reviews).

Upload your documents – don’t fax them
We encourage you to take advantage of the provider portal to upload documents in support of your UM review. To add more information, go into the original preauthorization request using the Reference ID and use the upload documentation feature.

Increased file size for attachments
We have increased the file size for documents attached to preauthorization requests to 25 MG so you can send more information at one time.

Optimal time to attach documents
The optimal time to upload documents is on the first Attach Documents screen in the preauthorization request, but you will be able to upload more later if you think of something else that could be helpful.

A few clicks can save hours or days
You can obtain faster preauthorization and concurrent review decisions by clicking Submit Request on the new MCG screen at the end of applicable request transactions. Some MCG screens will ask for additional information to help us avoid follow-up calls.

Electronic determination letters
No more waiting for your mail carrier to bring your determination letters for New York commercial members. Utilization review determination letters are now being added to the Preauthorization Details page in the portal. The person submitting a preauthorization request will be able to designate themselves or someone else to receive an email when the letter is posted. Everyone who can look up the preauthorization will be able to see the letter(s) connected to the request. Additional letters will be added to the portal, as explained in this notice.

Portal administrators
It’s important to us that our members’ protected health information (PHI) is always safe. Here are some good habits to adopt in protecting our members’ information:

Schedule time to periodically audit your portal users.
Deactivate portal accounts for staff* who have left your organization.
Make sure your staff is assigned to the tax IDs, providers, and roles that match their job’s required access to conform with HIPAA’s minimum necessary standards.

*When a provider leaves our network, the provider portal account is automatically updated to a special inactive user status. They will be able to view information, but not submit new transactions. This means portal administrators only need to actively update non-provider staff user accounts for those who should not have portal access.

Provider portal emails
Miss any of our emails with tips for making the best use of the portal? Click the topics below to see what you may have missed:

See if a provider is in-network for a member.
Where to Submit Information Using the Provider Portal.
Where is the Message Center?
When to Use the Message Center?
Addressing Denied Claims.
Customizable Downloadable Claims Reports.
Finding Explanations of Payments (EOPs).
PCP Panel Reports.
Enhancements for Inpatient Facilities.
Enhancements for Home Care Agencies.
Enhancements for Ambulance Companies.
Enhancements for Surgeons.
Enhancements for Vein Clinics.
Enhancements for Sleep Centers.
1Q Review Your Provider Portal Users.
2Q Review Your Provider Portal Users.
3Q Review Your Provider Portal Users.

Help and Support

Check frequently asked questions and answers before contacting Customer Service.

Get SupportGet Support

Doctor wearing a headset and looking at his computer

We use cookies on this website to give you the best experience and to measure website usage. By continuing to use this website, you consent to these cookies. View our Privacy Policy here.

Search

Popular Tasks

The Bridge Program

2023-2024 Annual Provider Notification

What to Expect for 2024 & 2023 Year in Review

Key Things To Know

Your Resources

Help and Support