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 preauthorization rules, medical policies, care management programs, special utilization management programs, pharmacy information - including formularies, behavioral health and dental information, and more. This is also where you will find current code lists and a Preauthorization Lookup tool.
Be sure to regularly check the Clinical Corner section of our provider website for the latest updates.
Here is a summary of the key updates posted this last year and those anticipated for 2022.
You can find all EmblemHealth Preauthorization Lists posted to our website. Changes to the list will be posted to the Preauthorization Rules page, not the News page.
Preauthorization List Reductions and Updates for 2022
Good news! Starting Jan. 1, 2022, we are removing 99 codes from the EmblemHealth Preauthorization List, and ConnectiCare’s Preauthorization Requirements for Commercial and Medicare plans. This is part of an ongoing evaluation of our preauthorization lists and an effort to simplify the administrative burden for our providers.
Starting Feb. 1, 2022, five new CPT codes will require preauthorization. These new codes supplement the ones that already require preauthorization for Neurostimulators (63664), Potentially Unproven Services (Q2043), and Cosmetic & Reconstructive Surgery (54416, 54401, 54405). See the full list of CPT Codes and their descriptions on our websites:
Oncology Drug Management Program – 2021 Changes
In 2021, additional codes requiring preauthorization were added to the Oncology Drug Management Program and for Long Term Support Services (S5102, S5130, T1019, T1020, S5160, S5161, S9123, and S9124 for Medicaid members and S9123 and S9124 for Commercial members).
New Provider Portal: Preauthorization, Referral, and ER Admission/Notification Transactions
The new Provider Portal makes coordination of care easier. Spend less time on the phone and feeding documents into a fax machine. By using the portal instead of faxes, you help us get started on your reviews sooner since all the requests are legible.
The Preauthorization Check Tool was updated and now returns information for all EmblemHealth and ConnectiCare members.
With the introduction of the new Provider Portal, providers are now able to upload supporting documentation while creating a preauthorization request or afterwards to supplement the request. Providers are asked to only submit the request through the Provider Portal. If, however, a request is submitted over the phone or by fax, do not resend the same request through the portal. Only one request is needed.
TIPS: Referral transactions require all Users to select both the Referring Provider and the Servicing Provider. Referrals may be submitted up to 30 days after the date of service to support member access to care.
Here are some time-savers for hospital staff:
- Convenient ER admission and newborn notifications: No more need to call or fax; these transactions can now be done online for all our members. Hospitals can now notify us on the portal – for all EmblemHealth and ConnectiCare managed members – up to 60 days after an admission.
- Submit Post-Acute Care requests: You can now make requests on behalf of other providers if you are working on discharge planning requests such as skilled nursing facilities (SNF), long-term acute care health (LTACH), inpatient rehabilitation facility (IRF), home health care (HHC), durable medical equipment (DME), and ambulance services.
If you need help with these transactions or getting access to the portal, see these educational materials (guides and videos), and our Frequently Asked Questions webpage.
Referral Policy Updates
In 2021, SOMOS announced that its members will not require referrals to be seen by specialists.
Because of the COVID-19 State of Emergency, our Medicare Members with plans that traditionally require referrals may see specialists without referrals. When this changes, notice will be provided.
The “Do I need a referral?” - A Quick Guide now has updated resources, 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.
Care Management Programs
EmblemHealth and Connecticare’s Care Management programs provide members with a holistic and seamless clinical model throughout their care journey. We do this by putting members in the driver’s seat. We deliver tailored, high-impact programming that integrates physical and behavioral health and enhances their providers’ work. We provide condition-specific education to reinforce established treatment plans and ensure a thoughtful, member-centric experience to achieve their self-management goals. We can also assist in navigation and coordination support to ensure our members can obtain the necessary care and resources in the right setting.
- Care Management Programs: 800-447-0768
- Healthy Futures Pregnancy Program: 888-447-0337
- New York State Smoker’s Quitline (tobacco cessation): 866-697-8487
- ConnectiCare: 800-390-3522
Clinical Practice Guidelines
No changes were made in 2021. We encourage our providers to consult EmblemHealth’s and ConnectiCare’s Clinical Practice Guidelines (CPGs) for assistance in the treatment of acute, chronic (e.g. HIV), and behavioral health issues.
To ensure public safety and to 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, access the Regulatory Mandatory Reporting chapter of our online Provider Manual.
Medical Policy Updates
EmblemHealth’s Medical Policies are posted in Clinical Corner in an alphabetized list. Additions and changes are noted after the policy name in the table. Soon, the Pharmacy Medical Policies are going to be moved to their own dedicated page in the Pharmacy section of Clinical Corner.
Below, find the new and revised EmblemHealth medical policies published since December 2020. A similar list can be found in the ConnectiCare section of this annual notice regarding ConnectiCare’s Medical Policies.
- Lung Volume Reduction Surgery
- Visual Evoked Potential Testing for Pediatric Populations in the Primary Care Setting — Commercial/Medicaid
- Genetic Testing for Frontotemporal Dementia (FTD)
- Analysis of KRAS Status
- Artificial Intervertebral Discs
- Bariatric Surgery
- BRCA 1 and 2 Genetic Testing (Sequence Analysis/Rearrangement)
- Breast Implants and Reconstruction
- Breast Reduction Mammoplasty
- Capsule Endoscopy
- Carrier Screening for Parents or Prospective Parents
- Cosmetic Surgery Procedures
- Cryosurgical Ablation for Prostate Cancer
- Fecal Microbiota Transplant (FMT) For Recurrent Clostridium Difficile Infection
- Gene Expression Profiling
- Infertility Services (Commercial)
- Insulin Delivery Devices and Continuous Glucose Monitoring Systems
- Lipoprotein Subclassification Testing for Screening, Evaluation and Monitoring of Cardiovascular Disease
- Lyme Disease Diagnosis and Treatment
- Neuropsychological Testing
- Non-Invasive Helicobacter Pylori Testing
- Noninvasive Prenatal Testing (NIPT) for Fetal Aneuploidy
- Obstructive Sleep Apnea Diagnosis and Treatment
- Outpatient Cardiac Rehabilitation
- Phototherapy, Photochemotherapy and Photodynamic Therapy for Dermatologic Conditions
- Posterior Tibial Nerve Stimulation for Voiding Dysfunction
- Recurrent Pregnancy Loss
- Stereotactic Radiosurgery and Proton Beam Therapy
- Testing for Coronavirus Disease 2019 (COVID-19)
- Transcatheter Aortic Valve Replacement
- Transurethral Radiofrequency Micro-Remodeling for Female Stress Urinary Incontinence
- Vacuum-Assisted Wound Closure
- Varicose Vein Treatment
- Virtual Colonoscopy (CT colonography)
- Visual Electrophysiology Testing
- Prostatic Urethral Lift (PUL)
- Gender Affirming/Reassignment Surgery
Medical Technologies Database
Our Medical Technologies Database is routinely reviewed to ensure it is current. Dispositions apply to all lines of business unless otherwise indicated. This listing also captures annual procedure coding updates since December 2020. The database was updated with new 2021 CPT/HCPCS codes, as needed.
- Acessa System (laparoscopic radiofrequency ablation for uterine fibroids) (Added commercial, eff. 9/11/2021, to already-covered Medicare)
- Eversense Continuous Glucose Monitoring System (Commercial and Medicare)*
- ExoDx®Prostate IntelliScore (EPI) (Medicare only)
- FoundationOne Liquid CDx (Commercial and Medicare)
- Guardant360 LDT (Added Commercial to already-covered Medicare)
- Immunoglobulin heavy chain locus (IGH@) testing for acute lymphoblastic leukemia (ALL) and lymphoma, B-cell, to guide therapeutic decision making (Commercial, eff. 11/13, added to already-covered Medicare)
- Medtronic MiniMed 670G and 770G monitoring systems*
- Myocardial strain imaging (Commercial and Medicaid; added to already-covered Medicare)
- Nasal endoscopy, surgical; balloon dilation of eustachian tube (E.g., ACCLARENT AERA™ Eustachian Tube Balloon Dilation System, XprESS ENT Dilation System) (Medicare, Medicaid)
- Per-oral endoscopic myotomy (POEM) for the treatment of swallowing disorders (e.g., achalasia)Prostate cancer antigen 3 gene (PCA 3) screening for prostate cancer (Progensa® PCA3 test [Hologic®]) (Added Commercial to already-covered Medicare)
* Listed in EH Medical Policy, Insulin Delivery Devices and Continuous Glucose Monitoring Systems
- Boston Heart Cholesterol Balance® Test
- Cala Trio™ electrical stimulation of the external upper limb and peripheral nerves of the wrist for essential tremor
- Guardant Reveal™
- Monarch External Trigeminal Nerve Stimulation [eTNS] System for pediatric attention deficit disorder (ADHD)
- PIGF Preeclampsia Screen (PerkinElmer Genetics)
- PreTRM® (Sera Prognostics)
- PrecisionBlood™ (San Diego Blood Bank)
- Patient Specific Talus Spacer 3D-printed talus implant