EmblemHealth | 2020 Annual Provider Notification

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Annual Provider Notification Materials

EMB MB WEB Medicare Banner 1440X450 12 10 20

What to Expect for 2020 & Year in Review


2019 was a year of growth and success for EmblemHealth. Your valued partnership in caring for our members makes you a part of our success. We thank you and look forward to working with you in the year ahead. 


For 2020, we are excited to roll out changes to our utilization management program which cuts in half the number of procedure codes needing pre-authorization. This will save your practice time and money and will make it easier for members to get the care you recommend.


Please review and share the materials below with your clinicians and staff. This will help you align your practice with our policies and with regulatory requirements.

Are You Accessible to Your Patients?

Offering timely appointments and having coverage after hours is not only a contractual requirement, it is a key concern for our members. EmblemHealth and the Department of Health conduct audits to see if you’re accessible to your patients. You should become familiar with the “Appointment Availability Standards During Office Hours & After Office Hours Access Standards” located in the Provider Toolkit. You may also download it here  Please post these standards in your office for your appointment schedulers. Failure to comply with these standards may result in termination from our network. The standards also include a list of avoidable mistakes that count as audit failures. Please take the time to review these common errors to prevent them from happening to you.

Keep your directory information current

Please review your listings in our online directory so our members can find you. If something is not right, please let us know based on how you participate with us:

  • If you work for an organization that is delegated for credentialing, please ask your practice administrator to include the correction on the next dataset submission.
  • If your application was credentialed directly by EmblemHealth’s staff, review and make changes to your profile by signing in to your account.
  • If you do not have computer access, please send changes to our Provider Modifications team:
    • By fax: 877-889-9061
    • By mail: EmblemHealth, Attn: Provider Modifications, 55 Water Street, New York, NY 10041

Claims Corner is your resource

EmblemHealth implemented claims policy and coding guideline changes over the past year. Below is a summary of the posted updates. Be sure to check the Claims Corner section of our provider webpage for the latest updates. Information that previously appeared in the Utilization Management section has been moved to Clinical Corner. Staying current helps ensure a smooth claims process and can help increase timely payments. Note: Information that previously appearing in the Utilization Management section has been moved to Clinical Corner.



Appropriate use of modifiers

EmblemHealth follows the AMA coding guidelines and policies in accordance with CMS on the appropriate use of modifiers. EmblemHealth will deny the use of a modifier when outside of these guidelines.

  • Medical Policy Coding Changes for Ocular Photo screening and Otoacoustic Emission Testing
  • Modifier 25 or Modifier 59 must be appended to HCPCS codes G0442 - G0447 when reported with an unrelated Evaluation and Management (E/M) service.
  • Modifier QW (CLIA waived test) can only be appended to procedures designated as CLIA waived tests on the clinical laboratory fee schedule.
  • Non-physician practitioner claims will be denied if submitted on the same date of service as a physician claim, and when the primary diagnosis on the submitted claims match on the first three characters of any ICD10 regardless of Provider ID and specialty. See: Duplicate Claims from a Non-Physician Practitioner.

EmblemHealth updated its coding policies based on CMS guidance for:

  •  Endoscopic retrograde cholangiopancreatography (ERCP)
  • Evaluation and Management (E/M) Services with Pulmonary Diagnostic Procedures
  • Electroencephalogram (EEG)
    • Fundus Photography
    • Pilonidal Cyst or Pilonidal Sinus
  • ClaimsXten billing and reimbursement updates made in 2019:  Policy

The following policies were revised:

  • Respiratory Assist Devices (RAD), Airway Pressure Devices, and Oral Appliances/Devices
  • Inpatient transfers between acute care hospitals/facilities
  • Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
  • Payment policies for Surgical Pathology CPT Codes



The EmblemHealth timely filing time frame is now 120 days unless the participation agreement states an alternative time frame should be applied. See the EmblemHealth Provider Manual for full policy.

When submitting anesthesia claims in the 837P HIPAA Transaction, use qualifier ‘MJ’. Reimbursement will be calculated based on the time submitted.

Enroll in our free electronic funds program

PNC Bank handles electronic funds transfer and electronic remittance advice (ERA or 835) for EmblemHealth. Our PNC Remittance Advantage Program offers paperless claim payments and electronic remittances for free. Electronic transactions are fast, convenient, and lower the risk of lost or stolen payments. PNC Remittance Advantage combines direct electronic funds transfer payments with 835 electronic remittance advice.

Go to rad.pnc.com to enroll. If you need help, call 877-597-5489. You will need your provider ID number to enroll. You can find it on your paper remittance.

Enroll in our free electronic funds transfer program

Our PNC Remittance Advantage Program offers paperless claim payments and electronic remittances for free. Electronic transactions are fast, convenient, and lower the risk of lost or stolen payments. PNC Remittance Advantage combines direct electronic funds transfer payments with 835 electronic remittance advice. Go to rad.pnc.com to enroll. If you need help, call 877-597-5489. You will need your provider ID number to enroll. You can find it on your paper remittance.

For our ASO members who access our Bridge Network, separate registration is needed with PNC’s company ECHO Health. Payments through ECHO follow a different workflow than those which may be in place with ECHO’s parent company PNC. EFT elections must be made for ECHO even if in place for other EmblemHealth claims payments. See the Bridge Network Members and New Claims Payment Process for information on all payment options. If you have questions regarding your payment options, please contact ECHO at 888-492-0032.


TriZetto is our preferred electronic data interchange source

EmblemHealth and Cognizant Healthcare Services, LLC have teamed up to allow providers to submit electronic claims through Cognizant’s TriZetto Provider Solutions (TPS). EmblemHealth’s preferred electronic data interchange (EDI) connection is TPS. If you would like to connect directly to TPS for free, please complete the form. If you already use a clearinghouse, such as Ability, SSI, Availity, or ClaimLogic, your claims will be sent to EmblemHealth. There will be no changes and you do not need to complete the form.


Make sure you have your correct NPI on file

Sign in to your provider profile on emblemhealth.com to make sure you have the right National Provider Identifier (NPI) on file. Using an incorrect NPI can result in denied claims. Federal law mandates that health care practitioners use their unique, 10-digit NPI when submitting standard electronic health care transactions, such as claims.

Taxonomy codes are important

Remember to provide taxonomy codes on all EmblemHealth claims. The absence of these codes may result in incorrect payments or the inability of your patients to fill their prescription.

Taxonomy codes are administrative codes that identify health care professionals at both the individual practitioner and organizational level. These codes include information on the practitioner’s specialty.

  • You must register all taxonomy codes – Taxonomy codes are self-reported by registering with the National Plan and Provider Enumeration System (NPPES) and by claims submission. Taxonomy codes may be obtained by visiting the National Provider Identifier Registry website. It is critical to register all applicable taxonomy codes with the NPPES and to use the correct taxonomy code to assist EmblemHealth in the timely and accurate processing of claims.
  • How to submit taxonomy codes on your claims: Taxonomy codes on electronic claim submissions with the ASC, X12N, 837P,  and 837I format are placed in segment PRV03 and loop 2000A for the billing level, and segment PRV03 and loop 2420A for the rendering level. For paper CMS-1500 professional claims, the taxonomy code should be identified with the qualifier “ZZ” in the shaded portion of box 24i. The taxonomy code should be placed in the shaded portion of box 24j for the rendering level, and in box 33b preceded with the “ZZ” qualifier for the billing level.

At EmblemHealth, we’re committed to supporting the whole you. An important part of that commitment is making sure you’re informed about all the resources available to you.  To receive additional information please click here

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

Each year, all Medicare providers are required to complete the Special Needs Plan (SNP) Model of Care (MOC) training for each of the Dual Eligible SNPs in which they participate. This is required by the Centers for Medicare & Medicaid Services (CMS). Providers in the VIP Prime Network must complete the EmblemHealth SNP MOC provider training as well as the ArchCare Advantage HMO SNP Model of Care training.


Click-and-Learn Tutorials

Our step-by-step tutorials on our Learn Online page will guide you on:

  • How Do I Know Which Networks I Participate In?
    Make sure your staff knows the networks in which you participate. This reduces confusion when members schedule an appointment. It also helps speed up claims and billing, and that means you get paid sooner for your services.
  • How Do I Know Which Members Are In My Network?
    Be sure you are aware of the networks your members can access so you can keep their care in-network.
  • How Do I Update My Directory Information?
    Keep your directory information up to date, especially the phone number to be used for making appointments and setting up after-hours coverage, to help with care coordination. While you are checking your information, please make sure we have a current/accurate email address, specialty(ies), MMIS, NPI, and taxonomy code.

Educational Topics

Cultural Competency Continuing Education and Resources & Cultural Competency and Diversity Awareness Overviews

EmblemHealth offers cultural competency continuing education, as well as resources and cultural competency and diversity awareness overviews, to help you improve awareness and skills in addressing the health care needs of diverse patient populations. Learn how to recognize communication barriers and how to be sensitive to various beliefs, ages, identities, and traditions.

Live Seminars and Webinars for Providers

EmblemHealth offers instructor-led webinar opportunities to help you learn how to work with us, our vendor partners, and other useful topics. Visit our Webinars and Seminars page at emblemhealth.com/providers/events to register and access our current offerings. These include:

  • Overview in working with EmblemHealth
  • Free Pulse8 Webinars for Patient Management and ICD-10 Coding.

Health Literacy

The American Medical Association has created videos with case studies showing actual physicians and staff interacting with real patients with low health literacy. These instructional videos offer techniques and specific steps for physicians and their staff to help patients with limited health literacy.

Pri-Med Offers Free Continuing Medical Education (CME) Activities

Choose from a growing list of online Continuing Medical Education (CME) activities sponsored by Pri-Med. These activities address the latest research in multiple topic areas. Thoroughly examine a topic from all angles with five activity formats, including case studies, slide lectures, and clinical reviews. You can manage your learning, track credits online, and complete activities at your own pace.

Pri-Med also offers courses such as “HIV update for the non-ID specialist: What every clinician needs to know” and “Pre-exposure prophylaxis for HIV Infection.” Just 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, sexually transmitted diseases (STDs), and hepatitis C. For information on programs, initiatives and services, visit the AIDS Institute for 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.


Required training for mental health & substance abuse (MHSA) providers

The New York State Office of Mental Health (OMH), the Office of Alcoholism and Substance Abuse Services (OASAS), and the New York State Department of Health (NYSDOH) require EmblemHealth’s behavioral health providers to complete State-approved cultural competence training on an annual basis. To satisfy this requirement, providers must complete one of these two programs:

  1. OASAS-approved training. To access a list of OASAS approved trainers, see the NYS OASAS Training Catalog.
  2. Two Uniform Network Provider Training modules. To access these training modules, visit The Center for Practice Innovations (CPI) Learning Community.

More educational materials

OMH also offers a host of educational materials on its website for behavioral health providers.

Children’s Medicaid Health and Behavioral Health System Transformation

The Community Technical Assistance Center of New York (CTAC) offers a collection of training resources around the Children's System Transformation. This includes the transition to Medicaid Managed Care, the new Children and Family Treatment and Support Services, and the aligned Home and Community Based Services. These materials are intended to help prepare new NYS Medicaid Children’s providers for the transition to Medicaid Managed Care. Materials can also be found on the CTAC website.



To learn more about EmblemHealth's Network Benefit Plans please click here.

To see our summary of companies, networks, and benefit plans, click here.

For a list of benefit plans that do not require a referral, click here

For a list of frequently used numbers and websites, click here.

Provider Manual

Our online Provider Manual is an extension of your contract with us. It has information about your administrative responsibilities, contractual and regulatory obligations, and best practices for helping members navigate our delivery systems. Revisions are made as policies are renewed, new programs are introduced, and rules change.

Secure Provider Portal

Sign in to access our secure portal. You can check member eligibility and benefits, review claims status,  update your practice information, create a referral, request pre-authorization, and more.

EmblemHealth Neighborhood Care

EmblemHealth Neighborhood Care provides in-person customer support, access to community resources, and programming to help the community learn healthy behaviors. Members and non-members alike can visit Neighborhood Care and take advantage of our classes, tools, and face-to-face support. Our health and wellness classes support the different dimensions of wellness, including physical, financial, social, and emotional. Neighborhood Care does not provide medical services. Instead, our role is to help practitioners manage patient care by supporting the practitioner-patient relationship.