2025-2026 Annual Provider Notification

See our Summary of Lines of Business, Networks, and Plans.

What to Expect for 2026 & 2025 Year in Review

Welcome to the 2025-2026 Annual Provider Notice! Here you can find policy updates made in the last year, required trainings, and learn about major transformations:

In 2026, we are introducing new rules for the Bridge Program that will be used exclusively for the City of New York Employee PPO plan (NYCE Plan). See our dedicated NYCE Plan page with its own frequently asked questions to help you become familiar with this new configuration.
Network Simplification: In most cases, starting Jan. 1, 2026, a member’s out-of-area coverage will be supported by Cigna’s Healthcare PPO Network*. Some members will, however, receive out-of-area care through First Health and QualCare. See the members’ ID cards for which extended network(s) applies. In addition, starting Jan. 1, 2026, EmblemHealth will no longer offer any of its networks to ConnectiCare members, nor will EmblemHealth members be able to see ConnectiCare providers on an in-network basis.
Prime Therapeutics is replacing Express Scripts, Inc. (ESI) as our pharmacy benefit manager (PBM) and replacing ESI and Evolent as our utilization review agent for our pharmacy medical benefits.

We are committed to supporting you and your practice in 2026 and beyond. We hope this information will assist you and your practice in continuing to provide exceptional, well-coordinated care to our members.

As always, visit our Provider Manual for guidance and reference on regulatory, policy, and accreditation requirements (such as provider rights, member rights and responsibilities, availability of criteria, and pharmacy procedures). Here are some of the most visited sections within the Provider Manual:

Credentialing Information | Member Rights and Responsibilities | Pharmaceutical Procedures

Care Management | Behavioral Health Services

*Members assigned to HealthCare Partners and SOMOS will continue to follow their administrative processes and will need to submit Emergency Room admission/newborn notifications directly to them. Our vendor partners who manage our Utilization Management Programs will continue to use their own websites and provider portals for transactions.

Key Things To Know

2026 Network and Benefit Plans

See the changes we are making to our 2026 offerings.

Patient Experience, Access to Care, and Quality Improvement

We value our members’ experience with us and with you, our contracted providers.

2026 Pharmacy Changes

Working with Prime Therapeutics.

doctor working at computer in the office

Learning Online: Training and Educational Opportunities

Required and recommended learning opportunities for Providers.

Clinical Corner

Stay current with key clinical updates and changes for 2026.

Doctor and nurse talking in hospital and looking at document

Behavioral Health: Mental Health & Substance Abuse

We provide options that can help you manage mental health and substance abuse.

patient and doctor smiling and looking at notes

Claims Corner

Payment integrity, reimbursement, and administrative guidelines.

At EmblemHealth, we are committed to ensuring a positive experience for our members — and that starts with you, our valued contracted providers. A member’s experience often begins with their use of our provider directories, so we kindly ask that you keep your listings accurate and current.

Once members select a provider, their next experience is appointment scheduling. Members expect their providers to schedule timely appointments and to know whether their services require referrals or preauthorizations.

Members also have the right to receive care that is culturally competent, non-discriminatory, and delivered with dignity. In turn, we expect our members to respect you and to honor their responsibilities as patients.  

Health care professionals play a vital role in improving clinical outcomes. Providers who follow established guidelines and best practices are successfully increasing quality measure scores and patient satisfaction ratings. We encourage you to use the following links, with resources and information to support high-quality care for our members and outline the way we measure clinical outcomes:

Easy Access to Key Resources  

Continuous Quality Improvement 

EmblemHealth has adopted the Institute for Healthcare Improvement (IHI) and the Centers for Medicare & Medicaid Services (CMS) Triple Aim for Healthcare Improvement, which focuses on:

Improving the health of our members.
Enhancing the member care experience.
Reducing the per capita cost of care.

See our Provider Manual and Quality Improvement page to access program brochures and performance tips, and to learn more about our robust Quality Improvement Program (QIP) that includes detailed metrics, coding guidance, and provider tools to help you succeed.  

Remind Members to Self-Monitor Blood Pressure

Remind our members with hypertension that EmblemHealth covers automatic blood pressure monitors for members diagnosed with hypertension. There is no member cost share or preauthorization requirement for members diagnosed with hypertension, provided they meet coverage criteria. See full article.

Please note that Chapter 5: Member Policies and Rights of the Provider Manual has been updated to remove the “Reproductive Health Care Privacy” section, since that part of the Final Rule issued in 2024 has been repealed.

Supporting Better Outcomes for Patients

One of the ways you can support better outcomes for your patients is with Transitional Care Management (TCM), which involves follow-up care for patients recently discharged from a hospital or other care center.

TCM can help:

Reduce risk of hospital readmission.
Improve health outcomes.
Align with Centers for Medicare & Medicaid Services (CMS) quality measures like Plan of All-Cause Readmission (PCR).

Prime Therapeutics™: Our New Pharmacy Benefits Manager (PBM) and Utilization Management Vendor for Pharmacy

New for 2026! EmblemHealth is teaming up with Prime Therapeutics to deliver pharmacy benefits with advanced claims technology and fast, reliable home delivery via Amazon Pharmacy*. Starting Jan. 1, 2026, we are also transitioning and consolidating utilization management for our medical pharmacy benefits. The following preauthorization requirements will continue to apply until Dec. 31, 2025:

You will soon see an updated pharmacy chapter in the EmblemHealth Provider Manual with details but here are some changes you can expect to see.

2026 Formulary Updates
See EmblemHealth Formularies for 2026 changes and full formularies.

Our Find a Network Pharmacy tools can help you and your members find a nearby participating pharmacy.

Prime Therapeutics Replacing Express Scripts and Evolent

Starting Jan. 1, 2026, Prime Therapeutics will replace Express Scripts and Evolent as our utilization review agent for infusion therapy.

Home Infusion Updates

Starting Jan. 1, 2026, home infusion preauthorization rules are changing. They will be published on Prime Therapeutics website soon. No preauthorization from Prime Therapeutics will be needed for:

Registered nurse visits.
Per diem codes.
Some drugs are being removed from the preauthorization list in 2026. List will only show those drugs that require a preauthorization from Prime Therapeutics.

Site of Service Policy – Infusions and Injectables

Reminder: We have site of service rules for EmblemHealth’s commercial members** when receiving infusion therapy. Where they get their care can impact their out-of-pocket costs. The updated Site of Service Medical Policy – Infusions and Injectables will be published on Prime Therapeutic’s website soon.

Arranging for Infusion Therapy

If you have a patient who needs infusion therapy, please see if they can take advantage of the concierge experience we created with New York Cancer & Blood Specialists (NYCBS).

For help finding an optimal infusion setting for your patient, email us at homeinfusionteam@emblemhealth.com.

*Exceptions will apply. Child Health Plus members will continue to have home delivery through Express Scripts, Inc. (ESI) and Medicare members will be able to choose between Amazon and ESI.

**See policy for exceptions.

The Learning Online section of our provider website is filled with required and recommended learning opportunities.

Here is a sample 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 and Network Access Network.
Required Medicare Training on Fraud, Waste, and Abuse.
Cultural Competency Continuing Education and Resources.
Health Literacy.
Free Continuing Medical Education (CME) Activities Sponsored by Pri-Med.
HIV/AIDS Education.
LGBTQ+ Education.

Free Veradigm Webinars for Patient Management and ICD-10 Coding

Veradigm offers free webinars for patient management and ICD-10 coding training. To register, go to our Veradigm Webinars page to see topics and dates. Click the Registration button at the bottom, then the Public Event List link and search by the webinar date or title of interest.

If you have any questions, or you would like to set up a private training session for your practice, please email Veradigm at providerengagement@veradigm.com or call Veradigm’s Customer Support team at 410-928-4218, option 7, from 8 a.m. to 8 p.m., Monday through Friday.

You can also learn more about the risk adjustment program here.

HIV/AIDS and Sexually Transmitted Diseases

Pri-Med offers HIV/AIDS and sexually transmitted infection (STI) education courses such as "You Got This! From Fear to Empowerment: Finally Integrating HIV and Sexual Health Services into Your Practice". To locate these courses, 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, STIs, and hepatitis C. For information on programs, initiatives, and services, visit the AIDS Institute for additional 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.

The Clinical Corner section of the EmblemHealth provider website is part of the EmblemHealth Provider Manual. It houses Administrative Guidelines described in our participation agreements. This is where you will find:

Visit the Clinical Corner for the latest updates.

Below is a summary of the key updates posted in 2025 and those planned for 2026.

Surgeons: Site of Service Rules Started Aug. 1, 2025

Starting Aug. 1, 2025, EmblemHealth began requiring preauthorization for certain hospital outpatient surgeries (places of service 19 and 22) for all members under age 75. Only surgeries that are clinically appropriate in a hospital setting will be approved. See Notable Changes for the specific services and codes that will require preauthorization along with other changes to the list including the removal of 303 services.

The same surgeries scheduled in an ambulatory surgery center (ASC) or doctor’s office will not require preauthorization. Surgeons are encouraged to obtain privileges at an ASC so their patient’s insurance can cover procedures that will not be approved in a hospital outpatient setting.

We are provided advance notice of this change to allow surgeons a three-month grace period to partner with an ASC. If you still need to find an ASC to partner with, see this list to find a participating ASC that is accepting new doctors for the surgeries you perform.

Concierge Programs

Our concierge programs help deliver seamless, high-quality care for our members while supporting provider efficiency. Current programs include:

Outpatient Surgical Concierge Program in New York City.
Total Joint Replacement Concierge Program.
New York Cancer & Blood Specialists (NYCBS).

Care/Case Management Programs

EmblemHealth’s Care Management programs can assist providers by helping coordinate care across care settings and ensuring members receive the right care in the right setting. See our Care/Case Management Programs page for program details, referral information, and contact options.

For general assistance, you can call 800-447-0768 from 9 a.m. to 5 p.m., Monday through Friday.

Diagnosis Code Updates

Before submitting a preauthorization request or elective inpatient admission notification, you can update diagnosis codes directly on the Review Details page. See our Tip Sheet for guidance.

Clinical Practice Guidelines

We encourage our providers to reference EmblemHealth’s Clinical Practice Guidelines (CPGs) for assistance in the treatment of acute, chronic (e.g., HIV), and behavioral health conditions. Our Medical Policy Committee last reviewed the CPGs in July 2025.

Medical Policy Updates

EmblemHealth’s Medical Policies are posted in the Clinical Corner.

At the end of 2025, the current Pharmacy Medical Policies, Enterprise Pharmacy Medical Policies, and Evolent – Medical Oncology Policies will be archived and labeled “expired.” Starting Jan. 1, 2026, all pharmacy-related medical policies will be available on Prime Therapeutic’s website.

The Site of Service Utilization Guidelines was reinstated Aug. 1, 2025.

Below are EmblemHealth Medical Policies revised in the past year:

Clinical Trials (Medicare).
Continuous Passive Motion Devices.
Fetal Surgery.
Gene Expression Profiling.
Gene Expression Profiling and Biomarker Testing for Breast Cancer.
Neuropsychological Testing.
Obstructive Sleep Apnea Diagnosis and Treatment.
Orthognathic Surgery.
Pain Management.
Phototherapy, Photochemotherapy and Photodynamic Therapy for Dermatologic Conditions.
Posterior Tibial Nerve Stimulation for Voiding Dysfunction.
Radiofrequency Ablation of Tumors.
Varicose Vein Treatment.

Mandatory Reporting

Providers must comply with federal, state, and local laws requiring the reporting of certain public health conditions. Review the Regulatory Mandatory Reporting chapter of our online Provider Manual for agency contact information and reporting requirements.

The Claims Corner section of our provider website is part of the EmblemHealth Provider Manual, and houses our Payment Integrity Policies, Reimbursement Policies, and Administrative Guidelines outlined in our participation agreements. Visit this section frequently for the latest updates. Below is a recap of changes from the past year:

New and Updated Policies

Payment Integrity Policies

The following formalized and new Payment Integrity Policies were introduced or updated this past year:

Device, Implant and Skin Substitutes Coding Guidelines (Facilities).
Annual Fee Schedule Updates – CMS and Medicaid.

Reimbursement Policies

The following Reimbursement Policies were introduced in the past year (Laboratory Benefit Management program policies are noted with “LBM”):

Habilitative and Rehabilitative Services.
Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS).
Nutritional Counseling Services.
Specialty Pharmacy Requirements Drug List.
Therapeutic Drug Monitoring of 5-Fluorouracil (LBM).

Updated Reimbursement Policies

The following Reimbursement Policies were revised. Please see each policy’s revision history for effective dates and specific changes:

Allergen Testing (LBM).
Ambulatory Surgical Groupers.
Assistant at Surgery – Modifiers 80/81/82 and AS (Commercial).
B-Hemolytic Streptococcus Testing (LBM).
Biochemical Markers of Alzheimer Disease and Dementia (LBM).
Biomarker Testing for Autoimmune Rheumatic Disease (LBM).
Biomarkers for Myocardial Infarction and Chronic Heart Failure (LBM).
Bone Turnover Markers Testing (LBM).
Bundled Services (Commercial and Medicare).
Cardiovascular Disease Risk Assessment (LBM).
Celiac Disease Testing (LBM).
Cervical Cancer Screening (LBM).
Coding Edits.
Colorectal Cancer Screening (LBM).
Compression Garments.
Computer Assisted Surgical Navigation.
Coronavirus Testing in the Outpatient Setting (LBM).
Diabetes Mellitus Testing (LBM).
Diagnosis of Idiopathic Environmental Intolerance (LBM).
Diagnosis of Vaginitis (LBM).
Diagnostic Testing of Common Sexually Transmitted Infections (LBM).
Diagnostic Testing of Influenza (LBM).
Diagnostic Testing of Iron Homeostasis & Metabolism (LBM).
Discarded Drugs/Biologicals – Modifiers JW and JZ (Commercial).
Discontinued Procedures – Modifiers 53, 73 & 74 (Commercial).
DME Rental vs. Purchase.
Emergency Department (ED) Facility E&M Coding (Commercial and Medicare).
Epithelial Cell Cytology in Breast Cancer Risk Assessment (LBM).
Evaluation and Management (E&M) Services.
Evaluation of Dry Eyes Testing (LBM).
Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing (LBM).
Fecal Calprotectin Testing in Adults (LBM).
Flow Cytometry (LBM).
Folate Testing (LBM).
Gamma-glutamyl Transferase (LBM).
General Inflammation Testing (LBM).
Helicobacter Pylori Testing (LBM).
Hepatitis Testing (LBM).
Hospital Readmission.
Human Immunodeficiency Virus (HIV) (LBM).
Identification of Microorganisms Using Nucleic Acid Probes (LBM).
Immune Cell Function Assay (LBM).
Immunopharmacologic Monitoring of Therapeutic Serum Antibodies (LBM).
Immunohistochemistry (LBM).
Intracellular Micronutrient Analysis (LBM).
In Vitro Chemoresistance and Chemosensitivity Assays (LBM).
Lab Testing for the Diagnosis of IBD (LBM).
Laboratory/Venipuncture.
Lyme Disease Testing (LBM).
Measurement of Thromboxane Metabolites for ASA Resistance (LBM).
Metabolite Markers of Thiopurines Testing (LBM).
Modifier Reference.
Multiple & Bilateral Surgical Procedures.
Multiple Diagnostic Imaging Payment Reduction (Commercial).
Multiple Procedure Reduction Cardiology/Ophthalmology.
Nerve Fiber Density Testing (LBM).
Onychomycosis Testing (LBM).
Oral Cancer Screening and Testing (LBM).
Outpatient Diagnostic Imaging Self-Referral Payment.
Pancreatic Enzyme Testing for Acute Pancreatitis (LBM).
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing (LBM).
Pathogen Panel Testing (LBM).
Pediatric Preventive Screening (LBM).
Prenatal Screening-(Nongenetic) (LBM).
Prescription Medication and Illicit Drug Testing in the Outpatient Setting (LBM).
Preventive Care Services (Commercial).
Preventive Care Services (Medicare).
Preventive Care/Screening (Commercial and Medicaid).
Prostate Biopsy Specimen Analysis (LBM).
Prostate Specific Antigen (PSA) Testing (LBM).
Radiology Cardiology Ultrasound Bundling Rules (Administered by EviCore).
Radiology Cardiology Ultrasound Correct Coding Rules (Administered by EviCore).
Radiology Cardiology Ultrasound Frequency Rules (Administered by EviCore).
Radiopharmaceuticals and Contrast Media.
Robotic Surgery.
Salivary Hormone Testing (LBM).
Serum Testing for Evidence of Mild Traumatic Brain Injury (LBM).
Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease (LBM).
Serum Tumor Markers for Malignancies (LBM).
Split/Fragmented Billing.
Telehealth/Virtual Care Services.
Testing for Alpha-1 Antitrypsin Deficiency (LBM).
Testing for Diagnosis of Active or Latent Tuberculosis (LBM).
Testing for Vector-Borne Infections (LBM).
Testing of Homocysteine Metabolism-Related Conditions (LBM).
Testosterone Testing (LBM).
Thyroid Disease Testing (LBM).
Urine Culture Testing for Bacteria (LBM).
Urinary Tumor Markers for Bladder Cancer (LBM).
Venous Thrombosis Risk Testing (LBM).
Vitamin B12 & Methylmalonic Acid Testing (LBM).
Vitamin D Testing (LBM).

Reminder: New Site of Service Rules

· Beginning Aug. 1, 2025, EmblemHealth is requiring preauthorization for certain hospital outpatient surgeries (places of service 19 and 22) for all members under age 75. Only surgeries that are clinically necessary in a hospital setting will be approved. See Notable Changes for the specific services and codes that will require preauthorization, along with other changes to the list including the removal of 303 services. The same procedures performed in an ambulatory surgery center (ASC) or physician office will not require preauthorization.

Surgeons are encouraged to obtain privileges at an ASC so their patient’s insurance can cover procedures that will not be approved in a hospital outpatient setting.
We announced this change with a three-month grace period to allow time to establish ASC partnerships.

To find a participating ASC that is currently accepting new doctors for the surgeries you perform, see this list. Since each ASC may have its own process for granting privileges, reach out to them directly.  

For questions, contact our Provider Customer Service team using the Message Center or Live Agent Chat in the provider portal.

Your Resources

Provider Portal

Visit frequently asked questions, videos, and user guides for assistance.

Key Portal Updates
Provider Manual

View your administrative responsibilities, contract agreements, and how to help members navigate our delivery systems.

View Provider Manual
Provider Toolkit

Guides and quick references to help with the administration of our plans.

View Toolkit
Provider Newsletter

The Office Visit is our monthly newsletter. See editions you may have missed.

View Newsletters
Member Materials

Find materials you can give your members in support of your care plans.

See Member Materials
Neighborhood Care

Let us help you help our members. See how we can support you.

Learn more

Our provider portal is designed to make your work easier. If you need help to navigate the portal, view our frequently asked questions, videos, and user guides for step-by-step guidance through each transaction.

You can also complete the Provider Portal Registration Form for assistance if you’re not sure who manages accounts in your organization.

Make sure your staff is assigned to the tax IDs, providers, and roles that match their jobs’ required access to conform with HIPAA’s minimum necessary standards. When a staff person leaves your practice, or you change third-party billers, remember to inactivate their accounts.

What was new in 2025

Message Center: New “All Messages” Feature and Grievance and Appeal Status

You can view and follow up on the messages submitted by others with the same tax ID and security access attached to their portal role. This feature makes it easier for staff to collaborate, avoid duplicate submissions, and view past communications with Provider Customer Service originating in the portal, by phone call, or fax.

The steps you take to find a grievance or appeal’s status depends on whether you were the person who originally submitted the request.

If you submitted the request in the portal, check the status in your Message Center under My Messages. View this Guide and Video for step-by-step instructions on using the Message Center.
If you did not submit the request, contact Provider Customer Service: 866-447-9717.

Accumulators

You can now view benefit accumulators on the member Benefits and Eligibility Details page. This shows you how many claims we have received against covered services with benefit limits. If the benefit limit has been reached, you will need to obtain agreement from the member to pay for the services, in writing, prior to providing the additional care.

Specialized Area

In general, EmblemHealth requires all applicants for all networks to complete and keep current the Council for Affordable Quality Healthcare's (CAQH) credentialing application form. See Keep Your Directory Information Current.

An exception is the NCQA-recognized Specialized Areas, which is not a data element captured in the CAQH application. To update your Specialized Areas, use the Ask a Question button in the portal’s Provider Profile page.

Diagnosis Code Updates

Before submitting a preauthorization request or elective inpatient admission notification, you can update diagnosis codes directly on the Review Details page. See our Tip Sheet for guidance.

Help and Support

Check frequently asked questions and answers before contacting Customer Service.

Get SupportGet Support

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