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2020-2021 Provider Annual Notification - Clinical Corner

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The Clinical Corner section of our 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.


Below is a summary of the updates posted this last year. Be sure to check the Clinical Corner section of our provider website frequently for the latest updates.

EmblemHealth created a webpage dedicated to COVID-19 Updates and policies. It is frequently updated to reflect the newest decisions from New York State and CMS. Of note - providers are prohibited from charging members for PPE and must return any funds collected.



EmblemHealth put a Temporary TeleHealth Policy in place and has added telehealth benefits to many of its 2021 plan offerings. EmblemHealth's company ConnectiCare conducted a survey of both commercial and Medicare Advantage members who had telehealth visits with their doctor in April or May 2020.


Key Findings:

  • Members Find Telehealth Benefit Very Important When Choosing PCP: Members of all ages were satisfied with the care they received in telehealth visits since emergency began in March. A significant number of members (65%) say it's very important to have this benefit available when choosing a primary care provider.
  • Telehealth Highly Appeals to Younger Age Groups: Those under age 65 highly likely to use telehealth again. While Medicare members surveyed were fairly satisfied with their telehealth visits, a little more than 1/3 required a follow-up visit in person.
  • Use of Telehealth or In-Person Visits Depend on Reason for Visit: All members appreciate the value of face-to-face visits with doctors but also see telehealth as an important adjunct for its safety and convenience.


Flu Vaccines

Please make sure your patients are getting their flu shots this year. EmblemHealth conducted a study which shows how important New Yorkers think the flu shot is. Take a look:

EmblemHealth Fall 2020 Survey Results

EmblemHealth conducted a survey of 1,005 New Yorkers this fall to address concerns raised by the CDC of a possible "twindemic" of COVID-19 and the flu.

Key Findings:

  • More New Yorkers Getting Flu Vaccination This Year, Especially Seniors and Males: Nearly half (47%) of New Yorkers are more likely to get the flu vaccination this fall due to the ongoing coronavirus pandemic.
    • 98% of seniors who received the flu vaccination in the past three years are just as likely or more likely to get one this year.
    • More than half (53%) of male respondents responded that they are more likely to get a flu vaccination this year compared to 42% of females.
  • Expect More Primary Care Appointments to Get Flu Vaccinations: 42% of New Yorkers plan to make an appointment with their primary care physician to get their flu vaccination. This is followed by 18% who would walk-in to a local clinic (no appointment).
  • Prepare for Walk-ins To Get Flu Vaccination in Manhattan and Brooklyn: New Yorkers in Manhattan and Brooklyn are more likely to walkin to a local clinic (no appointment) than the Bronx and Queens respondents.
  • New Yorkers Trust PCPs Most To Administer Flu Vaccination: Aligning with the main location to receive flu vaccinations for New Yorkers, the majority (63%) trust their primary care physician to administer their flu vaccination. This is followed by 44% who trust a nurse or medical assistant, and 41% who trust any doctor to administer their flu vaccination.

Utilization management decisions

EmblemHealth is dedicated to providing quality care and service to all our members. We do not make any payment, directly or indirectly, to a physician, physician group, or other practitioner as an inducement to reduce or limit medically necessary services. When conducting utilization review, EmblemHealth bases all decisions solely on the appropriateness of care and services, existence of coverage, benefit design, appropriate place of service, medical necessity, and applicable state and federal law. In addition, staff making utilization management (UM) decisions do not receive financial incentives or rewards for issuing denials of coverage and are not encouraged to make improper denials.

Availability of utilization management criteria upon request

In addition to publishing utilization management criteria in the EmblemHealth Provider Manual and in Clinical Corner, EmblemHealth makes the criteria available upon request:

  • By telephone at 866-447-9717.
  • Through the Message Center on our secure provider portal.

Affirmative statement regarding incentives

EmblemHealth distributes a statement to all members, practitioners, providers, and employees who make UM decisions, affirming the following:

  • UM decision making is based only on appropriateness of care and service, and existence of coverage.
  • EmblemHealth does not specifically reward practitioners or other individuals for issuing denials of coverage.
  • Financial incentives for UM decision makers do not encourage decisions that result in underutilization.

The statement can also be found in the Provider Manual.

Member responsibility for self-care

Member rights and responsibilities include their responsibility to self-care. For a complete description of what members can expect of EmblemHealth and what responsibilities our members have to EmblemHealth, visit the member policies and rights section of the Provider Manual.

Check panel reports - schedule new patient visits

Managing a busy practice is a challenge, and welcoming new members is an important part of providing care. We encourage our primary care physicians to routinely check their panel reports and reach out to new patients to schedule an initial visit. Please log in to our provider portal  to find your reports and more. Please encourage new Medicare and Dual Eligible Special Needs Plan (SNP) members to complete and submit their Health Risk Assessments.

Dispute resolution

All members have the right to dispute a determination that results in a denial of payment and/or covered services. The process, terminology, filing instructions, applicable time frames, and additional rights (including external review rights) vary based on the type of plan in which the member is enrolled. Our Provider Manual includes separate chapters on the dispute resolutions for:

  • Commercial & Child Health Plus plans.
  • Medicare plans.
  • Medicaid/HARP plans.

We will not attempt to terminate a practitioner agreement or disenroll a member who disputes a determination.


Referral Requirements

In 2020, we updated our provider portal to simplify the referral transaction by removing data entry steps from the workflow. We also increased the time frame to 30 days for back dating referrals. We surveyed our primary care practitioners and learned many are not staffed five days a week to process transactions. Where trusted referral practices are in place, we do not want the referral process to become a barrier to care. Specialist claims will still require a referral on file to avoid a denial. Please check to see the referral is in place before submitting claims.

In 2021, EmblemHealth is further reducing the number of plans requiring referrals. Please share this quick reference with your staff who schedules appointments so they can see which plans do not need referrals.

Preauthorization Requirements

Medical Preauthorization Changes
In 2020, EmblemHealth introduced a reduced list of services requiring preauthorization. We added Preauthorization Look-Up tools to our pre-login provider website and post-login provider portal. We also updated our provider portal to allow preauthorization requests for EmblemHealth, Inc. (formerly GHI).


Pharmacy Utilization Management
In August 2020, Express Scripts, Inc. (ESI) began pharmacy utilization management for commercial members for most medications. See announcement. Starting January 1, 2021, ESI will also manage most medications for Medicare, Medicaid, and HARP members. Also starting January 2021, New Century Health will manage chemotherapy and other oncology-related drugs. See announcement.

New Managing Entity

On October 11, 2020, SOMOS Community Care IPA (SOMOS) became the Managing Entity for the Medicaid, HARP, CHPlus, and Essential Plan members assigned to PCPs in their practice. This is the logo that will appear on the member ID Cards: 

SOMOS is responsible for conducting most utilization management and claims processing for their assigned members. To set up a SOMOS account, go to: SOMOS Portal. Hospitals should continue to submit ER Admission Notifications on emblemhealth.com. Unlike members assigned to Montefiore CMO and HealthCare Partners, SOMOS members participate in our vendor-run utilization management programs. Providers should follow the same processes in place for HIP-managed members covered by these UM programs.

Concurrent Review (DRG Inpatient Stays)

For inpatient stays after July 20, 2020 that fall under a diagnosis-related group (DRG) payment system, facilities only need to provide clinical information for the initial length of stay and for discharge planning unless:

  • The facility plans to bill charges in addition to the DRG (commonly referred to as “outlier charges”).
  • The facility requests a review where:
    • a member’s circumstances are unique.
    • a prolonged hospital stay is expected and outlier charges are likely to apply.
    • the circumstances around a member’s stay or discharge are more complex than normally expected for the diagnosis.
    • the member needs case management.
    • the member does not feel comfortable leaving the facility even though it is medically appropriate.

Clinical Practice Guidelines

The following Clinical Practice Guidelines were updated:

  • Appropriate Use of Antibiotics for Adults and Children
  • Asthma
  • Cholesterol Management for Adults at Risk for
  • Cardiovascular Disease
  • Chronic Kidney Disease
  • Chronic Pain
  • Congestive Heart Failure
  • Diabetes Mellitus
  • Helicobacter Pylori
  • AIDS & HIV Infection
  • Hypertension
  • Low Back Pain Diagnosis and Treatment
  • Obesity & Weight Management in Adults
  • Obesity & Weight Management in Children and
  • Adolescents
  • Preconception Care
  • Prenatal / Postpartum
  • Stroke Prevention
  • Treatment of Tuberculosis
  • Urinary Incontinence
  • Opioid Related Disorders
  • Treating Substance Use Disorders
  • Telemental Health
  • Use of Antipsychotics to Treat Agitation or Psychosis in
  • Patients with Dementia
  • Adult Preventive Services

EmblemHealth’s Medical Policies are posted in Clinical Corner in an alphabetized list. Additions and changes are noted after the policy name. Below, find the new and revised medical policies published since December 2019:



  • Acupuncture for Chronic Lower Back Pain – Medicare
  • EEG Ambulatory Monitoring
  • EEG Noninvasive (Commercial/Medicaid)
  • Foot Surgery (Commercial)
  • gammaCore Sapphire CV for the Coronavirus Disease 2019 (COVID-19)
  • Testing for Coronavirus Disease 2019 (COVID-19)


  • MCG — Bone Mineral Density Studies in Adult Populations


  • Acupuncture - EmblemHealth Medicare HMO Plans with Acupuncture Benefit
  • Amniotic Membrane Transplantation for Ocular Reconstruction
  • Balloon Sinuplasty
  • Breast Implants and Reconstruction
  • Gender Affirming/Reassignment Surgery
  • Gene Expression Profiling
  • Gene Expression Profiling and Biomarker Testing for Breast Cancer
  • Glaucoma Surgery
  • Home Birth Midwifery Services
  • Home Uterine Activity Monitoring (HUAM)
  • Ilizarov Technique
  • Infertility Services – Commercial
  • Insulin Delivery Devices and Continuous Glucose Monitoring Systems
  • Lipoprotein Sub-Classification Testing for Screening, Evaluation and Monitoring of
  • Cardiovascular Disease
  • Lymphedema Treatment
  • MYvantage® Hereditary Comprehensive Cancer Panel
  • Noncoronary Vascular Stents
  • Neuropsychological Testing (NPT)
  • Ocular Photo-screening
  • Outpatient Cardiac Rehabilitation
  • Posterior Tibial Nerve Stimulation for Voiding Dysfunction
  • Prostatic Urethral Lift (PUL)
  • Rhinoplasty
  • Varicose Vein Treatment


  • Noninvasive Prenatal Testing (NIPT) for Fetal Aneuploidy

Our medical technologies database is routinely reviewed to ensure it is current. Dispositions apply to all LOBs unless otherwise indicated. This listing also captures annual procedure coding updates since December 2019.


  • Biosynthetic fistula plugs for enteric/anorectal fistula repair (Commercial and Medicaid added to already-covered Medicare)
  • Companion Diagnostics
  • Coronavirus (COVID-19) diagnostic testing (e.g., CDC 2019-Novel Coronavirus [2019-nCoV] Real-Time RT-PCR Diagnostic Panel)
  • Drug-eluting sinus stents
  • gammaCore Sapphire CV for COVID-19
  • Genomic sequencing analysis for acute myelogenous leukemia (AML)/myelodysplastic syndromes (added Commercial & Medicaid to already covered Medicare)
  • Guardant360® CDx plasma companion to Tagrisso (osimertinib) for the therapeutic management of non-small cell lung cancer (NSCLC)
  • High intensity focused ultrasound (HIFU) for recurrent prostate cancer
  • NPM1 gene analysis (CPT 81310 — NPM1 [nucleophosmin] [eg, acute myeloid leukemia] gene analysis, exon 12 variants) (added Commercial and Medicaid to already-covered Medicare) Approved
  • Percutaneous mechanical thrombectomy (PMT) for deep vein thrombosis (DVT)/pulmonary embolism (PE) (Added Commercial and Medicaid to already-covered Medicare)
  • RUNX1 gene expression profiling for acute myeloid leukemia/familial platelet disorder with associated myeloid malignancy (Commercial and Medicaid added eff. 11/14, to already-covered Medicare)
    • Transcatheter mitral valve repair (TMVR), percutaneous (MitraClip®) (added Commercial and Medicaid; Medicare members fall under Medicare’s Coverage with Evidence Development NCD)
  • Transtelephonic spirometry for monitoring pulmonary function following lung or heart-lung transplantation (Added Medicare to already-covered Commercial and Medicaid)
  • Waterjet ablation (PROCEPT BioRobotics AquaBeamblation™ System) for benign prostatic hypertrophy (BPH)


  • Cryoablation — CT-guided, adrenal gland
  • Myoelectric Arm Orthosis (powered upper extremity range of motion assist device, elbow, wrist, hand) (i.e., MyoPro®)
  • New technologies (“T” HCPCS codes); shown with July effective dates
  • Percutaneous electrical nerve field stimulation (PNFS) for functional pain in children and adolescents with irritable bowel syndrome (IBS) (E.g., IB-STIM®)

EmblemHealth Care Management provides 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

Kidney Care Program (in partnership with OptumHealth Kidney Resource Services serving end-stage renal disease and chronic kidney failure stages 4 & 5): 866-561-7518

New York State Smoker’s Quitline (tobacco cessation): 866-697-8487

To ensure public safety and to track conditions affecting public health, 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.

Communicable Disease Reporting

New York State and New York City health laws require practitioners to report suspected or confirmed cases of communicable diseases to the patient’s local health department. View the New York State reporting guidelines at health.ny.gov. EmblemHealth conducts a monthly Communicable Disease Record Audit to ensure practitioners comply with regulations. Practitioners are chosen at random based on a review of reportable diagnoses identified by the New York State Department of Health.

New information on electronic test requests, accessing laboratory reports, and a revised Wadsworth Center infectious diseases requisition form

The Wadsworth Center is introducing electronic submission protocols to increase efficiency, turnaround time, tracking accuracy, and availability of information. See here for full information.

Requesting tests electronically through the Health Commerce System (HCS) is preferred and recommended. If an electronic test request is not possible, submitters are asked to use Infectious Diseases Requisition form DOH-4463 (6/19) available for download.

For questions or further information, please contact the Wadsworth Center at wcid@health.ny.gov or 518-474-4177.

Citywide registry reporting

Health care professionals who care for Medicaid and Child Health Plus members are also required to report vaccines they give to their patients to the Citywide Immunization Registry and Lead Poisoning Prevention Program. New York City’s Health Code Article 11 requires certain diseases and conditions be reported to the Department of Health and Mental Hygiene immediately and others within 24 hours. Visit the New York City Department of Health and Mental Hygiene website. For immediate consultation on public health issues, call the Provider Access Line at 866-692-3641.