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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.

 

Utilization & Medical Management

Pre-Authorization Requirement Changes

EmblemHealth is changing its approach to pre-authorization requirements. In September 2019, we introduced supplemental site-of-service requirements for HIP and HIPIC Commercial and Medicaid members. The site-of-service rules define procedures that do not require a pre-authorization if performed in certain office settings (POS 11) or in an ambulatory surgery center (POS 24). These site-of-service rules will be modified effective January 1, 2020 to remove the need for pre-authorizations for the listed services for pediatric patients (birth to 18 years old).
 

Also starting January 1, 2020, we will reduce your need to seek pre-authorization based on the member’s type of plan. There will be specific requirements for Commercial, Medicaid, and Medicare members. Overall, we will be eliminating more than 1,000 unique codes. The same rules apply to all managing entities (HIP, Montefiore CMO, and HealthCare Partners).
 

Effective January 1, 2019, Empire Blue Cross Blue Shield (BCBS) added additional services to its precertification list for site-of-service review for groups utilizing the NYC Healthline to obtain a reference number. More.

GHI PPO members rolling into additional UM programs

As non-City GHI PPO members’ plans renew and these members are moved onto our new claims platform, they will be included in the following special programs:

Click on the program name above to see the applicable Provider Manual chapter for detailed instructions. To identify members who have been migrated, look to their member IDs. If the ID starts with the letter “K” followed by a 10-digit number, the program or policy applies.
 

Medicare members transitioning from Montefiore CMO to EmblemHealth in 2020

On January 1, 2020, Montefiore CMO’s responsibility as Managing Entity for Medicare members will transition to EmblemHealth. EmblemHealth will be responsible for claims payment and utilization, case, and disease management services. Providers will need to be registered to use the secure provider portal at emblemhealth.com/provider to manage applicable referral and pre-authorization transactions. See a quick reference card for using the provider portal. Members in case and disease management programs are being outreached to facilitate the transition.
 

Skilled nursing: utilization management

eviCore only manages members in Skilled Nursing, Inpatient Rehab, and Long-Term Acute Care facilities for 90 days. Thereafter, you will need to contact EmblemHealth at 888-447-2884 to address ongoing inpatient days.

AdvantageCare Physicians introduced “easy referrals”

On September 1, 2019, AdvantageCare Physicians introduced “easy referrals” with a new nine-digit numbering format. These new formats are valid numbers recognized by our claims systems. There will be a transition period when the old numbers will be honored. Here are the three types of referral numbers you will see in the coming months:

Referral number formats

Samples

The letters PF followed by 12 numbers

PF997210789217

The letters QF followed by 12 numbers

QF997210903217

New: nine numbers only

002008078

 

No referrals needed for initial evaluation of PT, OT, and radiology

EmblemHealth is making it easier for providers and members regarding referrals. For initial evaluation of physical therapy (PT) and occupational therapy (OT) services, providers no longer have to obtain a referral. A referral is also not necessary for x-rays and other radiology tests.

This applies to those services that do not require pre-authorization. If a service requires pre-authorization, you should continue to contact Palladian for PT and OT and eviCore for radiology services or applicable Managing Entity (Montefiore CMO or HealthCare Partners).
 

EmblemHealth hospital readmission policy

We changed our hospital readmission policy to more closely align with the Centers for Medicare & Medicaid Services (CMS) guidance. Beginning August 1, 2019, in the event a second admission is deemed to be a continuation of the first, EmblemHealth no longer:

  • Reopens the first admission.
  • Adds the new inpatient days.
  • Allows the facility to rebill for a combined admission.

Instead, when the second admission is denied as a continuation of the first admission, a denial is mailed along with facility grievance rights. In the event the denial is overturned, and the new services are found to be independent and medically necessary, the facility needs to submit a new claim to cover these new services. EmblemHealth no longer accepts or processes a combined claim.

 

Clinical Practice Guidelines

Clinical Practice Guidelines

The following Clinical Practice Guidelines were updated:

  • Lead Screening
  • Lyme Disease
  • Osteoporosis
  • Pediatric and Adolescent Preventive Services
  • Rheumatoid Arthritis
  • Sexually Transmitted Diseases (including recommendations for HPV vaccination)
  • Smoking Cessation

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. Below, find the new and revised medical policies published since December 2018:
 

NEW

  • Ajovy (fremanezumab-vfrm)
  • Anesthesia for Dental Procedures and Oral and Maxillofacial Surgery — New York
  • Automatic Blood Pressure Monitor
  • Dental Care or Treatment Necessary Due to Congenital Disease or Anomaly — New York
  • Dental Trauma Guidelines for Medical Plans
  • Elzonris (Tagraxofusp-erzs)
  • Gamifant (Emapalumab-lzsg)
  • Glaucoma Surgery
  • Khapzory (levoleucovorin)
  • Ocular Photoscreening
  • Parsabiv (Etelcalcetide)
  • Revcovi (Elapegademase-lvlr)
  • Site of Service Utilization — Commercial/Medicaid
  • Telehealth Commercial/Medicaid
  • Ultomiris (Ravulizumab-cwvz)

 

REVISED

  • Acupuncture - EmblemHealth Medicare HMO Plans with Acupuncture Benefit
  • Bariatric Surgery
  • Blepharoplasty
  • BRAF Mutation Analysis
  • BRCA 1 and 2 Genetic Testing (Sequence Analysis/Rearrangement)
  • Capsule Endoscopy (camera pill)
  • Doula Services - Medicaid
  • Gene Expression Profiling
  • Gene Expression Profiling and Biomarker Testing for Breast Cancer
  • Genetic Testing for Colorectal Cancer/Lynch Syndrome
  • Insulin Delivery Devices and Continuous Glucose Monitoring Systems
  • Mechanical Stretching Devices
  • Medical Necessity Guidelines: Experimental, Investigational or Unproven Services
  • Noncoronary Vascular Stents
  • Obstructive Sleep Apnea Diagnosis and Treatment
  • Orthognathic Surgery
  • Osteochondral Grafting
  • Osteogenesis Stimulators
  • Otoacoustic Emissions Testing
  • Periurethral Bulking Agents for Urinary Incontinence
  • Posterior Tibial Nerve Stimulation for Voiding Dysfunction
  • Radiofrequency Ablation for Tumors
  • Sacroiliac Joint Fusion
  • Selective Internal Radiation Therapy
  • Stereotactic Radiosurgery and Proton Beam Therapy
  • Transcatheter Aortic Valve Replacement
  • Vagus Nerve Stimulation for Epilepsy

 

Medical Technology Updates

Our medical technologies database is routinely reviewed to ensure it is current. Changes are announced in our provider newsletter, In the Know, and posted on our provider website in Clinical Corner.

Dispositions apply to all LOBs unless otherwise indicated. This listing also captures annual procedure coding updates.
 

Approved:

  1. Electroretinography (ERG) with interpretation and report, pattern (PERG)
  2. Gene expression profiling — AFF2 (AF4/FMR2 family, member 2 [FMR2]) (e.g., fragile X mental retardation 2 [FRAXE])
  3. Gene expression profiling — ATXN1 (ataxin 1) (e.g., spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (e.g., expanded) alleles
  4. Gene expression profiling — ATXN8OS (ATXN8 opposite strand [non-protein coding]) (e.g., spinocerebellar ataxia) gene
  5. Gene expression profiling — BTK (Bruton's tyrosine kinase), PLCG2 (phospholipase C gamma 2) (e.g., chronic lymphocytic leukemia) gene analysis
  6. Gene expression profiling — CACNA1A (calcium voltage-gated channel subunit alpha1 A) (e.g., spinocerebellar ataxia) gene
  7. Gene expression profiling — CNBP (CCHC-type zinc finger nucleic acid binding protein) (e.g., myotonic dystrophy type 2) gene
  8. Gene expression profiling — CSTB (cystatin B) (e.g., Unverricht-Lundborg disease)
  9. Gene expression profiling — DMPK (DM1 protein kinase) (e.g., myotonic dystrophy type 1) gene analysis (Commercial and Medicaid only)
  10. Gene expression profiling — EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (e.g., myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis
  11. Gene expression profiling — FXN (frataxin) (e.g., Friedreich ataxia) gene analysis (Commercial and Medicaid only)
  12. Gene expression profiling — HTT (huntingtin) (e.g., Huntington disease) gene analysis (Commercial and Medicaid only)
  13. Gene expression profiling — MYD88 (myeloid differentiation primary response 88) (e.g., Waldenstrom’s macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant
  14. Gene expression profiling — NUDT15 (nudix hydrolase 15) (e.g., drug metabolism) gene analysis
  15. Gene expression profiling — PABPN1 (poly[A] binding protein nuclear 1) (e.g., oculopharyngeal muscular dystrophy) gene analysis
  16. Gene expression profiling — PPP2R2B (protein phosphatase 2 re.g.ulatory subunit Bbeta) (e.g., spinocerebellar ataxia) gene analysis
  17. Gene expression profiling — SMN1 (survival of motor neuron 1, telomeric) (e.g., spinal muscular atrophy) gene analysis; dosage/deletion analysis (e.g., carrier testing)/ SMN2 (survival of motor neuron 2, centromeric) analysis (Commercial and Medicaid only)
  18. Gene expression profiling — TBP (TATA box binding protein) (e.g., spinocerebellar ataxia) gene analysis
  19. Gene expression profiling — TERT (telomerase reverse transcriptase) (e.g., thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis
  20. Gene expression profiling — TGFBI (transforming growth factor beta-induced) (e.g., corneal dystrophy) gene analysis
  21. MYvantage® Hereditary Comprehensive Cancer Panel (Quest)
  22. Nerve blocks for primary or secondary headache per LCD (Medicare only)
  23. Ross pulmonary autograft (aka Ross procedure)

 

Rejected:

  1. Cardiac — hemodynamic, transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed
  2. Cardiac — myocardial imaging by magnetocardiography (MCG) for detection of cardiac ischemia, by signal acquisition using minimum 36 channel grid, generation of magnetic-field time-series images
  3. Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes set-up, patient training, configuration of monitor, data upload, analysis and initial report configuration, download review, interpretation and report
  4. Extracorporeal shockwave therapy for integumentary wound healing, high energy
  5. Gene expression profiling — AR (androgen receptor) (e.g., spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis
  6. Intraprocedural coronary fractional flow reserve (FFR) with 3D functional mapping of color-coded FFR values for the coronary tree, derived from coronary angiogram data, for real-time
  7. Intraoperative visual axis identification using patient fixation
  8. Pharmacogenetic testing — IFNL3 testing for drug response (interferon) gene analysis
  9. PK Papyrus Covered Coronary Stent System (Covered for on-label use only commensurate with FDA Humanitarian Device Exemption)
  10. Tarsi Implant — removal /removal and reinsertion

 

2019 Pre-authorization Changes for Some Medications

EmblemHealth resumed direct management of injectable drug utilization. Pre-authorization requirements for some medications changed in 2019. To submit a pre-authorization request, fax it to: 877-243-4812 or call 888-447-0295.
 

EmblemHealth’s specialty pharmacy & coverage of Stelara

Accredo is EmblemHealth’s specialty pharmacy. To order medications, contact Accredo using accredo.com; or call them at: 855-216-2166.

The self-injectable drug, Stelara, available through Accredo, became part of the pharmacy benefit for our commercial members effective Jan. 1, 2019. Stelara infusion continues to stay covered under the medical benefit.
 

Vaccines for Children (VFC) – billing and reimbursement for covered vaccines

Join the VFC Program to provide no-cost vaccines for eligible Medicaid members under 18. Learn more.

Prescriptive Authority Claims Adjudication

Medicare and Medicaid providers are responsible for maintaining an accurate national provider identification (NPI) number and taxonomy code in the National Plan and Provider Enumeration System (NPPES) database. Missing or incorrect information in the national database could prevent Medicare and Medicaid patients from filling prescriptions for controlled substances.

Primatene Mist returned to OTC

Primatene Mist (epinephrine) returned to over-the-counter (OTC) shelves in its new HFA formulation. It is indicated for relieving mild-to-moderate symptoms of intermittent asthma in patients age 12 and up.
 

Pharmacy Guidelines adopted in 2019

These new pharmacy guidelines can be found at https://www.emblemhealth.com/providers/resources/toolkit/medical-policies.

 

  1. Azedra (Iobenguane I-131)
  2. Colony Stimulating Factors: Udenyca (pegfilgrastim-cbqv)
  3. Crysvita (burosumab-twza)
  4. Ilumya (tildrakizumab-asmn)
  5. Krystexxa (pegloticase)
  6. Kyprolis (carfilzomib)
  7. Mepsevii (vestronidase alfa-vjbk)
  8. Mvasi (bevacizumab-awwb)
  9. Onpattro (patisiran)
  10. Poteligeo (mogamulizumab-kpkc)
  11. Radicava (Edaravone)
  12. Rituxan Hycela (rituximab and hyaluronidase Human)
  13. Tremfya (guselkumab)
  14. Velcade (bortezomib)

 

Formulary Updates

To determine whether a drug is covered by a member's benefit plan, visit formulary_updates in Clinical Corner.  EmblemHealth communicates its pharmaceutical updates and pharmaceutical management procedures to members and prescribing practitioners through eblasts, in the Provider Manual, and on our website.

These include the following information:

  • Covered pharmaceuticals
  • Pharmaceuticals that require prior authorization, step therapy, or quantity limits
  • Pharmaceuticals with limited availability
  • Tier information

Quality Improvement

EmblemHealth has adopted a model of Continuous Quality Improvement as a core business strategy in medical (including pharmaceutical and dental), behavioral health care, and other services provided to a complex, culturally and language-diverse membership. Our Executive and Management teams use data-driven, decision-making methodologies in the strategic planning process. EmblemHealth has 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 to learn more about our Quality Improvement Program.
 

Performance management

Performance related to patient care is continuously being assessed by regulatory agencies. Their goal is to make sure patients get the most appropriate care for the best possible result. These include:

  • Healthcare Effectiveness Data and Information Set (HEDIS)* – a tool that measures care and service provided to patients.
  • Quality Assurance Reporting Requirements (QARR) – captures the quality of that care.
  • Health Outcomes Survey (HOS) – allows Medicare patients to report on their own current health status.
     

These show areas where there is room for improvement. Use the results to guide your patient care efforts.

Here are some non-clinical tips to boost your measurement scores:

  • When billing, use the correct codes that relate to ALL services given during the visit.
  • Be sure to include the codes with the most specific definition of the diagnosis, procedure, and/or associated result. This may reduce chart collection.
  • Remember to:
    • Bill with appropriate Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and International Classification of    Diseases (ICD) codes.
    • Give the health plan access to the member’s medical record or encounter data.
    • Closely follow Clinical Practice Guidelines.
    • Use codes associated with HEDIS/QARR value sets.

Health care professionals have the greatest impact on clinical outcomes. Those who follow established guidelines and best practices are successfully increasing quality scores and patient satisfaction.

*HEDIS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).
 

The Consumer Assessment of Healthcare Providers and Systems (CAHPS)* survey

The Consumer Assessment of Healthcare Providers and Systems (CAHPS)* survey is an annual survey used to measure patients’ experience with their doctor and doctor’s office. It asks about getting appointments quickly, ease of getting needed care, ease of communicating with staff and doctors, getting help in coordinating care, flu vaccination, and the overall experience of getting care. Positive experiences result in better survey ratings. The sections below include tips for improving the patient experience that you can apply in your practice.

* CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).

 

EmblemHealth has developed a guide you may find useful when you provide care. It’s called “How You and Your Office Staff Can Improve the Patient Experience.” Find it by clicking on “Improving the Patient Experience” from our Provider Toolkit in the Welcome to EmblemHealth section.
 

Keep accurate medical records and comply with submission requests

CMS requires you to keep accurate, complete, and legible patient records. EmblemHealth performs annual medical record data collections for HEDIS and New York State Department of Health QARR. You may be asked to send us records as part of this requirement. As a reminder, if you use a service to store and retrieve requested records, you may not bill EmblemHealth for this service.
 

Panel reports help close gaps in preventive care

When EmblemHealth identifies gaps in care, we notify members, educate them about the importance of the needed service, and encourage them to discuss the topic with their doctors. To make sure you know about these gaps in care, we send you panel reports identifying the patients and their issues so you can address any needed care.
 

New York State Department of Health (NYSDOH) 2019-2020 KIDS Quality Performance Improvement Project

EmblemHealth is committed to increasing the quality and efficiency of pediatric screenings for children within their first 1,000 days of life – between the ages of 0 and 3. As part of this quality initiative with the New York State Department of Health, you may receive a copy of our comprehensive early screening pocket reference guide, “The First 1,000 Days.” This reference guide provides information on early identification, prevention, diagnosis, treatment, intervention, and follow-up care for lead exposure, newborn hearing loss, and developmental disorders. You may also access this valuable practice resource online by going to the Provider-Toolkit.
 

Reducing HPV-related cancers

EmblemHealth is working in collaboration with the American Cancer Society, New York State and City Departments of Health, and other New York State health plans to encourage more providers to recommend the HPV vaccine and help reduce the rate of HPV-related cancers. This action guide can help you and your practice deliver a strong and effective recommendation for the HPV vaccination series.
 

Increasing colorectal cancer screening rates

We are working with Quest Diagnostics on a program aimed at increasing colorectal cancer screening rates for our members. Selected Medicare and Medicaid members will receive an outreach phone call from us offering an InSure® ONE™ collection kit. Primary care providers will be sent test results for inclusion in the members’ medical records and for follow-up action as medically appropriate.

Care Management Programs

Coordination of care: an integral part of patient care

Navigating a complex health care system can be a challenge, but coordinating services among all primary and specialty providers, and care settings is essential for ideal patient care. This is especially true as conditions and care needs change over time.

Our Care Management programs are focused on keeping members healthy. We monitor and use various types of information including medical and pharmacy claims data and social determinants of health (e.g., transportation issues and access to food) to identify and support members who have multiple complex health conditions or are at risk for a chronic condition. This data can help us flag and manage members with emerging risk, assess their health, and find opportunities to increase patient safety.
 

The programs support your care plans by using evidence-based clinical practice guidelines to emphasize how members can prevent complications and flare-ups of chronic conditions. The following programs are voluntary and available to all members who meet eligibility requirements:

  • Care Management programs – 800-447-0768
  • Healthy Beginnings Pregnancy – 888-447-0337
  • Kidney Care (for end-stage renal disease or chronic renal failure stages (4&5), we partner with OptumHealth Kidney Resource Services) – 866-561-7518
  • New York State Smoker’s Quitline (tobacco cessation) – 866-697-8487

 

Behavioral Health

Updated Behavioral Health Screening Tools Now Available

To help you identify behavioral health conditions in your EmblemHealth members, please use our updated behavioral health screening tools. If you refer a member to one of our behavioral health services programs, please follow through to coordinate care.
 

Collaborative activities

EmblemHealth annually conducts activities to improve behavioral health and general medical care, including collaboration with behavioral health practitioners. These include:
 

Practitioners’ opportunities for collaboration, continuity, and coordination of care:

  • Improve the process for members to authorize sharing of behavioral health information.
  • Implement primary care guidelines for assessing, treating, and referring common behavioral problems.
  • Increase non-behavioral health care practitioner satisfaction with feedback from behavioral health care practitioners.
  • Improve procedures for treating hospitalized members with coexisting medical and behavioral health conditions.
  • Improve management of elderly members with indications of depression and multiple behavioral health care medications.
  • Educate primary care practitioners about appropriate indications for referring patients with hyperactivity disorder or depression to behavioral health care specialists.
  • Facilitate communication between a medical practitioner and the behavioral health care practitioner who is treating the medical practitioner’s patient.
  • Implement a prevention program for behavioral disorders commonly managed in the primary care setting.|

 

EmblemHealth promotes:

  • Exchange of information between behavioral health care and medical practitioners.
  • Appropriate diagnosis, treatment, and referral of behavioral health disorders commonly seen in primary care.
  • Appropriate use of psychotropic medications.
  • Oversight of access to treatment and proactive follow-up for members with coexisting medical and behavioral disorders.
  • Preventive behavioral health care program implementation in both primary and secondary settings.
  • Accommodations to be made for the special needs of our members with severe and persistent mental illness.

 

Confidentiality for domestic violence or endangered victims

 

Please let your affected patients know they are entitled to these privacy protections:

  • Group policy members may request we enforce an order of protection against the policyholder or other person. We will not disclose their address or telephone number for the duration of the order.
  • We will accommodate any reasonable request for a covered individual to receive communications of claims-related information by an alternative means or at an alternative location. The member must give us a valid order of protection or let us know he/she is a victim of domestic violence and will be in danger by the disclosure of certain information.

 

Mandatory Reporting

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.

 

ALSO OF INTEREST

Behavioral Health Clinical Practice Guidelines Table 23-3, Appeal - Contracted Facility Clinical Appeal Claims Corner
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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.