2021 Annual Provider Notification

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2020-2021 Annual Provider Notification

Smiling male doctor talking with older male patient.

What to Expect for 2021 & Our 2020 Year in Review


2020 will go down in history as uniquely challenging for us all. However, every crisis presents an opportunity. EmblemHealth’s response to COVID-19 has made us more nimble and resilient as individuals and as a company, with the ability to overcome pandemic-related disruptions. We have learned to support each other in new ways and have developed a deep sense of gratitude for your valued partnership in caring for our members. We thank you and look forward to working with you in the year ahead. 


Please note: We have new Medicare networks for individual and group members launching in 2021: VIP Prime, VIP Bold, and VIP Reserve. Only Prime, which will serve groups, will require referrals. For information, see the Network and Benefit Plans tab below. 


Please review and share the materials below with your clinicians and staff. This streamlined recap of 2020 guidance and what you’ll need to know for 2021 will help you care for your patients. 


As always, for continued guidance and reference on regulatory, policy, and accreditation requirements, please visit our comprehensive Provider Manual here: https://www.emblemhealth.com/providers/manual. Below are some of the more in-demand links from the Provider Manual: 


Information Link
Credentialing Information https://www.emblemhealth.com/providers/manual/credentialing
Member Rights and Responsibilities https://www.emblemhealth.com/providers/manual/member-policies-andrights
Pharmaceutical Procedures https://www.emblemhealth.com/providers/manual/pharmacy-services
Care Management https://www.emblemhealth.com/providers/manual/care-management
Provider Portal https://www.emblemhealth.com/providers/resources/provider-sign-in
Clinical and Behavioral Health https://www.emblemhealth.com/providers/2020-annual-providernotification/clinical-corner

To see our summary of companies, networks, and benefit plans, click here.  This is an extension of our provider agreement(s) which defines our 2021 offerings.

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

To learn about EmblemHealth's New Medicare Networks &  Benefit Plans for 2021 as well as key operational, educational, and regulatory requirements, please click here to see our 2021 Medicare Advantage Guide.

To learn about EmblemHealth's new Commercial Networks &  Benefit Plans for 2021, please click here to see our plan offerings. 

To see our Medicaid/HARP/CHP Resource Guide: Anticipated 2021 Changes, 2020 News Recap, & Medicaid Compliance Requirements, please click here.

To learn about EmblemHealth's Bridge Program for 2021, please click here to see our updated guide. Note: Providers who are only contracted with EmblemHealth Plan, Inc. (fka Group Health Incorporated (GHI) are considered Bridge Program providers. Members should not be turned away.

To see our current list of network labs click here

At EmblemHealth, we value our members' experience with us and with you, our contracted providers. A member's experience often begins with their use of our provider directories. We ask you to keep your listings current. Once they have found the right provider, their next experience is appointment scheduling. Members expect their providers to schedule timely appointments and to know whether services need referrals or preauthorizations. They expect to be treated with dignity, in a culturally competent manner, free from discrimination, and to have their rights honored. We also expect our members to respect you and to honor their responsibilities.   


Health care professionals have the greatest impact on clinical outcomes. Those who follow established guidelines and best practices are successfully increasing quality measure scores and patient satisfaction. Following is information to help you meet members' expectations and ways we are measured in meeting them.      


Easy Access Resources   


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  


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.  


 Nondiscrimination rule  

Practitioners shall comply with all applicable laws prohibiting discrimination against any member and in accordance with the same standards and priority as the provider treats his/her/its other patients regardless of any of the following factors:  

  •  Age  

  • Amount of payment  

  • Claims experience  

  • Color  

  • Creed  

  • Disability  

  • Ethnicity  

  • Evidence of insurability (including conditions arising out of acts of domestic violence)  

  • Gender  

  • Genetic information  

  • Health literacy  

  • Health needs  

  • Health status  

  • HIV status  

  • Language  

  • Marital status  

  • Medical history  

  • Mental or physical disability or medical condition  

  • National origin  

  • Need for health services  

  • Place of residence  

  • Plan membership  

  • Race  

  • Religion  

  • Sex  

  • Sexual orientation  

  • Source of payment  

  • Type of illness or condition  

  • Veteran status  

  •  In addition, providers are to comply with:  

    • Age Discrimination Act of 1975  

    • Americans with Disabilities Act  

    • Title VI of the Civil Rights Act of 1964  

    • Terms of the plan’s contracts with NYSDOH and/or CMS  

    • Health Insurance Portability and Accountability Act  

    • HIV confidentiality requirements of Article 27-F of the Public Health Law and Mental Hygiene Law  

    • Section 1557 of the Affordable Care Act (ACA) of 2010  

    • Other laws applicable to recipients of federal funds, and all other applicable laws and rules, as required by applicable laws or regulations  


Member Rights and Responsibilities and Your Activities  

Member rights and responsibilities are distributed to new and existing members, and are available to new and existing practitioners in the provider manual. The rights and responsibilities include their providers:  

  • treating them with respect.   

  • recognizing their dignity.   

  • respecting their right to privacy.   

  • allowing them to participate in making decisions about their health care.   

  • discussing treatment options for their condition(s) candidly regardless of cost or benefit coverage.   

  • voicing complaints or appeals about the organization or care.  

  • making recommendations regarding their rights and responsibilities.  

Members are responsible for:  

  • understanding their health problems.  

  • participating in the development of mutually agreed-upon treatment goals.  

  • following plans and instructions for care to which they have agreed.  


Continuous Quality Improvement  

 We have adopted a model of Continuous Quality Improvement in medical (including pharmaceutical and dental), behavioral health care, and service provided to a complex, culturally and language diverse membership as a core business strategy. Our Executive and Management teams use data-driven, decision-making methodologies in the strategic planning process. We have 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 member care is continuously being assessed by accreditation and regulatory agencies. The goal is to make sure members receive and are satisfied with  the most appropriate care for the best possible safe result. Tools used to measure member receipt of and satisfaction with care include:   


  •  Healthcare Effectiveness Data and Information Set (HEDIS)* – a tool which measures care and service provided to members.   

  • Quality Assurance Reporting Requirements (QARR) – captures the quality of that care.   

  • Health Outcomes Survey (HOS) – allows Medicare patients to report their own current health status.   

  • The Consumer Assessment of Healthcare Providers and Systems (CAHPS®)* survey is an annual survey used to measure patients’ experience with the health plan, and access to 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 which you can apply in your practice.   


These results help to 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 which 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 HEDISR/QARR value sets.  


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

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

For full information about our mental health and substance abuse (MHSA) services available to your patients, see the Behavioral Health chapter of the EmblemHealth Provider Manual. We partner with Beacon Health Options (for all members) and Montefiore’s University Behavioral Health (only for Monte CMO members) to provide and to manage MHSA services. To find a provider for your EmblemHealth members, use Find A Doctor.  

Collaboration is KEY!  

Physicians are encouraged to collaborate with behavioral healthcare practitioners and use information to coordinate medical and behavioral healthcare.  EmblemHealth evaluates the success of coordination of care by looking at the:  

  • exchange of information between behavioral health care and medical practitioners. 

  • appropriate use of psychotropics. 

  • appropriate diagnosis treatment. 

  • referrals of behavioral health disorders. 

  • treatment access. 

  • follow-up care for members with co-existing medical and behavioral health disorders. 

  • primary or secondary prevention and the special needs of members with severe and persistent mental illness.  


Behavioral Health Screening Tools   

Physicians can be the members’ first contact when in need of behavioral health services and/or medications.  Members tend to share symptoms, concerns, issues, and other needs with their PCPs rather than or before considering professional behavioral health services. Using behavioral health screening tools can help determine a diagnosis and related complications. The Behavioral Health section of Clinical Corner[RS1]  on our website includes screening tools that can quickly be used with a member via telephone, in person, email, telemedicine.  If you refer a member to one of our behavioral health services programs, please follow up to coordinate care. 


Collaborative activities 

EmblemHealth continually 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 ask us to 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 claim 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. 


If you think a patient is at risk, please let them know there are organizations ready to help. For a listing of domestic violence hotlines by county, go to the NYS Coalition Against Domestic Violence website: New York State Domestic Violence Programs County ListingEmblemHealth’s Neighborhood Care sites are also available to assist. You can find additional information on our Domestic Violence Guidelines page. 


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.

Claims Corner is your resource  

The Claims Corner section of our provider website is part of the EmblemHealth Provider Manual and houses Administrative Guidelines described in our participation agreements.  

EmblemHealth implemented claims policy and coding guideline changes over the past year. Below is a summary of the updates posted. Be sure to check the Claims Corner section of our provider website frequently for the latest updates.  



Timely Filing Reminder  

The EmblemHealth timely filing time frame is 120 days from the date of service, unless EmblemHealth is the secondary payor or the participation agreement states an alternative time frame to be applied. See the EmblemHealth Provider Manual for full policy.  


New free electronic funds program  

This summer, EmblemHealth partnered with ECHO Health, Inc., to facilitate claims payments for all members for all professional and facility claims. A project is currently underway to offer ECHO’s services to our dental network providers too.   

Through ECHO, you can receive direct deposits to your bank account(s) (known as electronic funds transfer (EFT)) and view or download your remittances online (known as electronic remittance advantage (ERA)). Electronic transactions are fast, convenient, and reduce the risk of lost or stolen payments. This solution is free and allows you to reduce payment processing costs and improve cash flow. Visit ECHO, click on the “Click Here” button, and follow the instructions to enroll. Learn more.   



New Claims Editor – Zelis 

EmblemHealth partnered with Zelis Healthcare to introduce a new editing tool to identify and show you billing errors, new edit codes and explanations prior to payment.  

Starting April 1, 2020, Zelis began applying edits to EmblemHealth’s HMO Commercial and Medicare products using industry standards sourced to the Centers for Medicare & Medicaid Services (CMS), the American Medical Association, and the ICD-10-CM manual. Zelis’ suite of edits complements the system currently in place


Reimbursement Policy  

The following reimbursement policies were revised:  

  • Anesthesia  

  • 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   


NPI & Taxonomy Codes  

Sign into your Provider/Practice Profile to make sure you have the right National Provider Identifier (NPI) and Taxonomy Code(s) on file. Using an incorrect code 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. The absence of taxonomy codes may result in incorrect payments or the inability of your patients to fill their prescription. 

Clinical Corner

Click here to see a summary of the updates posted this last year.  Be sure to regularly check the Clinical Corner section of our provider website frequently for the latest updates. 


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. 


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 - Special Needs Plan (SNP) Model of Care (MOC) training for providers in the VIP Bold Network. 

  • Cultural Competency Continuing Education and Resources   

  • Health Literacy 

  • Free Continuing Medical Education (CME) Activities Sponsored by Pri-Med  

  • HIV/AIDS Education 


Pri-Med 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. 


Annually, and as updates become available, providers can access the following in the EmblemHealth Provider Manual Pharmacy Services chapter, which includes the information posted in Clinical Corner:


  • A list of pharmaceuticals including restrictions and preferences.

  • How to use the pharmaceutical management procedures.

  • An explanation of limits and quotas.

  • Information to support an exception request.

  • Process for generic substitution, therapeutic interchange, and step-therapy protocols.


Utilization Management

On Aug. 3, Express Scripts, Inc. (ESI) began utilization management of all commercial members for most medications. See announcement.

Starting Jan. 1, 2021, ESI will begin utilization management of HIP's Medicare and Medicaid members for most medications. New Century Health will also begin management of chemotherapy drugs for commercial, Medicare, and Medicaid members. Members managed by HealthCare Partners and Montefiore CMS are exempt from these programs and will medically manage their own assigned membership. See announcement.



To see announcements of formulary changes, see our Formulary Updates webpage. To determine whether a specific drug is covered by a member’s health plan, use the applicable Formulary search:

Covid-19 Testing by Pharmacies

The New York State Department of Health (NYSDOH) has issued coding guidance for pharmacies engaged in COVID-19 testing Medicaid recipients, including our Medicaid and HARP members.


Step Therapy for Plan B Drugs – Effective January 1, 2021

Starting Jan. 1, 2021, EmblemHealth will recommend use of selected preferred products and will be implementing step therapy for the Medicare line of business for certain categories of Part B drugs. This change will not apply to our City of New York retirees.

Click here to see the selected preferred products and the step therapy protocols.

Prescriptive Authority Claims Adjudication

Medicare and Medicaid providers are responsible for maintaining an accurate National Provider Identifier (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.

Enhanced Care Prime Network Providers Must Register with the Medicaid Fee-For-Service Program

According to the NYSDOH, there are providers who are not registered with the Medicaid Fee-For-Service program (FFS Medicaid) who are prescribing medications for EmblemHealth members. We ask all providers in our Enhanced Care Prime Network to register with the FFS Medicaid program.

Medicaid/HARP Transition of Pharmacy Benefit from MMC to FFS – April 1, 2021

Starting April 1, 2021, we anticipate the NYSDOH will carve out drug coverage from Medicaid Managed Care plans. Our members will be expected to obtain their medication from Medicaid Fee-For-Service participating pharmacies who will submit claims to the State. See Transition (Carve-Out) of the Pharmacy Benefit from Managed Care to Fee-for-Service (FFS), Frequently Asked Questions (FAQs) on the DOH website.


Pharmacy Guidelines

These pharmacy guidelines are part of our Medical Policies. See the Clinical Corner Medical Policies section of this microsite to see 2020 changes.

EmblemHealth Introduced a Biosimilar Strategy – July 1, 2020

EmblemHealth selected preferred products for all lines of business for bevacizumab, trastuzumab, and rituximab. This does not apply to EmblemHealth Plan, Inc. (fka Group Health Incorporated (GHI)) City of New York members.

EmblemHealth’s Specialty Pharmacy

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

Vaccines for Children Program (VFC)

Our Medicaid and Commercial providers are required to join the VFC Program to provide no-cost vaccines for eligible Medicaid and Child Health Plus members under age 18.

Member access to pharmacy benefits

Members have access to complete the following on the website regarding pharmacy:

  • Determine financial responsibility based on the pharmacy benefit.

  • Initiate the exceptions process.

  • Order a refill for an existing, unexpired mail-order prescription.

  • Find the location of an in-network pharmacy.

  • Conduct a pharmacy proximity search based on ZIP code.

  • Determine the availability of generic substitutes.

For a list of frequently used phone numbers, addresses, 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.


How Do I?

The How Do I? page is a compilation of frequently asked questions and answers. Check here before contacting Customer Service.  


Member Materials 

This page offers materials you can give your members in support of your care plans. 


Provider Toolkit 

The Provider Toolkit has guides and quick references to help with the administration of our plans. The Toolkit is where we house Welcome materials for new providers.