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 last year and those anticipated for 2023.
New In-House Post-Acute Care Process Coming
Before the end of 2022, EmblemHealth will begin to manage post-acute care (PAC) for EmblemHealth members, replacing eviCore. This includes home health care, skilled nursing facilities, acute rehabilitation, and long-term acute care hospital admissions.
Once we announce the start date, you will need to contact EmblemHealth to help arrange for PAC services and support. Note: eviCore will continue to handle durable medical equipment for EmblemHealth members.
Upcoming webinars: To help you better understand how the insourcing of all PAC services and the Transitions of Care program affects the members in your care, we will host a series of informational webinars. Please join the session that’s best suited for your facility/provider type – no registration required. All sessions will be held via Microsoft Teams between
Nov. 8 and Nov. 17, 2022. For the full list of session dates and times, visit emblemhealth.com/postacutecare.
Attention home health care providers: Our provider portal has a Home Health Status report to give you a consolidated view of the preauthorization requests for the members under your care. See the quick guide and video on our Portal Training page in the Preauthorization section for instructions on how to create the Home Health Status report.
Additional support: We offer a Transitions of Care program to help members with complex care issues better manage their health after a hospital admission. Our team will work with the member to make sure they are educated about their condition, have needed resources, and get the right care to feel better. Program information is available to our members on the Live Well section of our member website.
Referral Policy Updates
NEW FOR 2023 — We are removing referral requirements for our Medicaid, HARP, Child Health Plus, and Essential Plan members.
Until the COVID-19 State of Emergency ends, our Medicare members with plans that traditionally require referrals may continue to see specialists without referrals. When this changes, notice will be provided.
The “Do I need a referral?” - A Quick Guide has updated resources for 2023, 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.
Visit our EmblemHealth Preauthorization Lists page to see what requires preauthorization and who is responsible for the utilization review. Updates to the lists are posted in the Notable Changes section. The Preauthorization Check Tool returns information for all EmblemHealth and ConnectiCare members.
Use the Provider Portal for Preauthorization, Concurrent Review, Referral, and ER Admission/Notification Transactions
The 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 the requests are legible. Upload documentation while creating a preauthorization request or afterwards by going back into the same preauthorization request to supplement the request and to provide concurrent review information.
New: Care Plans – Except for those with sensitive information, Care Plans developed through our Care/Case Management Programs are available through the Member Management section on the Eligibility Details screen. See Care Plans Training Guide and Video.
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.
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 can get the necessary care and resources in the right setting. To refer a member to one of our Care/Case Management programs:
EmblemHealth: See our Care 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.
Clinical Practice Guidelines
Four Clinical Practice Guidelines were updated in 2022:
- Adult Preventive Services
- Helicobacter Pylori
- Pediatric Adolescent Preventive Services
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.
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.
Medical Policy Updates
EmblemHealth’s Medical Policies are posted in Clinical Corner. Pharmacy Medical Policies are housed on the Enterprise Pharmacy Medical Policies and New Century Health—Medical Oncology Policies page.
Below, find the new and revised EmblemHealth medical policies published since December 2021 as well as those that have been retired. A similar list can be found in the ConnectiCare section of this annual notice regarding ConnectiCare’s Medical Policies.
New Medical Policies
Revised Medical Policies
- Bariatric Surgery
- BRCA 1 and 2 Genetic Testing
- Cardiac Event Monitors
- Gene Expression Profiling and Biomarker
- Hyperbaric Oxygen Therapy
- Lipoprotein Subclassification Testing for Screening, Evaluation, and Monitoring of Cardiovascular Disease
- Medical Necessity Guidelines: Experimental, Investigational or Unproven Services
- Non-Invasive Prenatal Testing (NIPT) for Fetal Aneuploidy
- Obstructive Sleep Apnea Diagnosis and Treatment
- Pain Management
- Radiofrequency Ablation for Spinal Pain
- Recurrent Pregnancy Loss
- Site of Service Utilization
- Testing for Breast Cancer
Retired Medical Policies
- Bunion/Hammertoe/Metatarsophalangeal Joint
- Functional Endoscopic Sinus Surgery (FESS)
- Intrastromal Corneal Ring Segments
- Noncoronary Vascular Stents
- Prostatic Urethral Lift
- Total Ankle Replacement
- Transurethral Radiofrequency Micro-Remodeling for Female Stress Urinary Incontinence
- Urine Drug/Alcohol Testing - Commercial/Medicaid (EH); was replaced by the enterprise-wide Reimbursement Policy for Drug and Alcohol Testing (Commercial/Medicaid)
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 2021.