2026-2027 Annual Provider Notification

Our Summary of Lines of Business, Networks, and Plans is an extension of our provider agreement(s). It defines our plan offerings.

To easily see if you or a provider you conduct business for is in-network for a given member, use the provider portal’s Check Provider Network Status tool, found on the “Member Details” page.

Refer to this list of 2027 Benefit Plans That Do Not Require a Referral when scheduling appointments, so you do not spend time creating or searching for referrals that are not needed.

Select the links below to learn about our 2026 plans and key operational, training, and regulatory requirements. The links go to permanent web pages where you can view product-specific information all year long.

• Bridge Program.
• Commercial Networks and Benefit Plans.
• Medicare Advantage Plans.
• Medicaid, HARP, and CHPlus (State-Sponsored Programs).

For additional reference, you can also review EmblemHealth’s Current List of Network Labs.

Partnering to Improve Quality and Member Experience

At EmblemHealth, improving quality outcomes starts with strong provider partnerships. We recently created a dedicated Quality Provider Engagement team. They help our primary care providers improve their quality scores, increase reimbursement under various incentive programs, and improve member health outcomes. This team uses resources to help providers close care gaps, improve preventive care, strengthen care transitions, support medication adherence, and create a positive patient experience.

Healthcare professionals play a critical role in helping members receive recommended screenings, manage ongoing conditions, and access timely follow-up care. See our Quality Improvement page to learn more about how you can improve member care.

Key Actions to Support Quality Performance

Close HEDIS^® Care Gaps

• Review member-level care-gap reports regularly and prioritize overdue preventive, ongoing-condition, and medication-adherence opportunities.
• Use every member interaction, including office visits, telehealth encounters, and follow-up calls, to address open gaps and schedule needed follow-up care.
• Submit complete claims, encounters, CPT II codes, and supplemental clinical data supported by accurate documentation so completed services are captured.

Do You Know Which of Your Patients Have Open Care Gaps?

Providers can access member-level care-gap information, quality performance reports, medication-adherence opportunities, and other quality resources through:

• Provider Portal reports for PCPs.
• Gaps in Care reports for PCPs and Ob/GYNs.
• Quality scorecards and performance reports for PCPs and OB/GYNs.
• Pharmacy and medication-adherence reports for PCPs.
• Provider engagement consultations and quality review meetings for PCPs and OB/GYNs.

For help accessing reports, interpreting results, or developing an improvement plan, contact Quality Provider Engagement.

Medication Adherence and Ongoing Condition Management

Medication adherence is a key focus for improving outcomes among members with ongoing conditions. Providers are encouraged to:

• Review medication regimens.
• Consider 90-day prescriptions when appropriate.
• Promote medication-management tools.
• Help members address barriers that make it difficult to take medications as prescribed.

Learn More

• Medication Adherence Tools and Resources
• Pharmacy Services Contacts
• Pharmacy Resources

See Full Stories

• Medication Adherence Tips
• New Materials to Support Medication Adherence

Improve Access and Member Experience

To support Consumer Assessment of Healthcare Providers and Systems (CAHPS^®) performance, practices should:

• Offer the earliest available appointment and explain alternatives when a requested appointment is unavailable.
• Promote same-day, after-hours, weekend, virtual, and urgent care options when available.
• Minimize wait times for appointments to start and telephone hold times. Return member calls promptly.
• Help members understand referrals, preauthorizations, medications, test results, and next steps while coordinating care across primary care, specialty care, behavioral health, pharmacy, and hospital settings.

One of the easiest and least expensive ways to influence a member’s perception is to simply greet them with a smile when they come into the office.

Strengthen Front-Desk and Phone Interactions

Front-desk and telephone staff are often a member’s first point of contact. Practices should ensure staff:

• Welcome members respectfully and listen carefully to their needs.
• Provide clear next steps rather than simply directing members elsewhere.
• Assist with scheduling, referrals, prescriptions, and care coordination whenever possible.
• Escalate urgent concerns and ensure members understand how their issue will be resolved.

Learn More

• Access, Availability, and After-Hours Coverage Standards
• Consumer Assessment of Healthcare Providers and Systems (CAHPS) Provider Tip Sheet
• Improving the Patient Experience: Information and Tips to Enhance Patient Interactions
• Keep Your Directory Information Current
• Member Rights and Responsibilities, Including Nondiscrimination Rules
• Cultural Competency Continuing Education and Resources

Cancer Screening and Early Detection

Breast, colorectal, and cervical cancer screenings are quality priorities. Providers are encouraged to identify members due for screening, discuss available testing options, address barriers to care, and include appropriate documentation in the medical record.

Early detection remains one of the most effective ways to improve outcomes and reduce the burden of disease.

Learn More

• Clinical Practice Guidelines
• Quality Improvement Resources

See Full Stories

• Breast and Colorectal Cancer Screenings Are Key Quality Measures
• March Is Colorectal Cancer Awareness Month
• January Is Cervical Cancer Awareness Month

Supporting High-Quality Maternity Care

The Maternity Quality Incentive Program recognizes and rewards providers for delivering high-quality maternity care while supporting improved prenatal and postpartum outcomes. See eligibility requirements on our Quality Improvement page.

Program priorities include:

• Timely prenatal visits.
• Timely postpartum visits.
• Completion of the Obstetrical Needs Assessment Form.
• Improved maternity-related quality outcomes.

Learn More

• 2026 Maternity Quality Incentive Program Guide

Program contact: Quality Provider Engagement

Supporting Better Outcomes After Hospital and Emergency Department Visits

Timely follow-up after hospital and emergency department visits is critical to improving outcomes and reducing avoidable readmissions. Practices should:

• Conduct timely follow-up after inpatient, emergency department, behavioral health, and substance-use-related care.
• Reconcile medications and review discharge instructions.
• Confirm that follow-up appointments are scheduled within the applicable measure time frame.
• Share information with treating providers and clearly document follow-up activities.

Learn More

• Transitions of Care Guide
• Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions Tip Sheet

See Full Stories

• Get Rewarded for Improved Transitions of Care
• Critical Medicare HEDIS Measure: Emergency Room Follow-Up

Additional Quality Priorities

Additional resources and reminders during 2026 focused on:

• Care for older adults.
• Depression screening and follow-up.
• Diabetic eye exams.
• Healthy aging.
• Immunizations.
• Kidney health evaluations.
• Newborn hearing screening.
• Osteoporosis management in women who had a fracture.
• Polypharmacy.

Learn More

• Quality Improvement Resources
• Clinical Practice Guidelines

See Full Stories

• Osteoporosis and Treating Women After a Fracture
• HEDIS Measure: Care for Older Adults
• Help Members Plan for Healthy Aging
• Encourage Patients With Diabetes to Schedule Retinal Exams
• AAP Recommends Universal Newborn Hearing Screening
• Increase Immunization Rates This Summer

Continuous Quality Improvement

EmblemHealth has adopted the Institute for Healthcare Improvement and Centers for Medicare & Medicaid Services 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.

Visit the Quality Improvement chapter of the Provider Manual and Quality Improvement Resources for program information, performance tips, detailed measures, coding guidance, and provider tools.

Provider Manual Update

The Member Policies and Rights chapter of the Provider Manual has been updated to remove the Reproductive Health Care Privacy section because that part of the Final Rule issued in 2024 has been repealed.

2027 Formulary Updates

See EmblemHealth Formularies for 2027 formulary changes and complete formulary information.

Providers and members can also use the Find a Network Pharmacy tool to locate participating pharmacies.

Medical Pharmacy Updates

Enhanced Drug Wastage (EDW) Program

As of Nov. 1, 2026, EmblemHealth implemented an Enhanced Drug Wastage (EDW) Program through Prime Therapeutics™. This medical drug policy initiative is designed to reduce medication waste and promote appropriate dosing of select provider-administered medications.

See Full Story: Enhanced Drug Wastage Program Through Prime Therapeutics

2027 Medical Pharmacy Management Updates

Review the table below to see the impacted drug classes and preferred product changes that take effect Jan. 1, 2027. These updates are intended to support appropriate prescribing, authorization submissions, and patient care planning.

2027 Preferred Medical Pharmacy Products

Advocate+ Pharmacy Match Program Enhancement: IntegratedRx®

As of Oct. 1, 2026, Prime Therapeutics™ updated the Advocate+ Pharmacy Match Program for select oncology and cystic fibrosis specialty medications through IntegratedRx. This program allows eligible members to receive medications through their care center’s in-house pharmacy, helping improve coordination between the pharmacy and treating physician.

See Full Story: Specialty Pharmacy Program Match

Resources: Pharmacy Services and Specialty Pharmacy Information

*The program applies to all fully insured EmblemHealth plans (i.e., Child Health Plus, Essential Plan, individual and family, NYSHIP, large group, and small group) and all EmblemHealth and AdvantageCare Physicians employees. Accredo will remain the specialty pharmacy provider for the New York City Employees PPO plan and certain other programs.

Reminders

Prime Therapeutics™ Is Our Pharmacy Benefits Manager and Utilization Management Vendor for Pharmacy

In 2026, EmblemHealth partnered with Prime Therapeutics™ to deliver pharmacy benefits, medical pharmacy management, and utilization management services.

Beginning Jan. 1, 2026, EmblemHealth:

• Transitioned and consolidated utilization management for medical pharmacy benefits.
• Replaced Express Scripts and Evolent with Prime Therapeutics as the utilization review agent for infusion therapy.
• Updated home infusion preauthorization requirements.
• Eliminated Prime Therapeutics preauthorization requirements for registered nurse visits and per diem codes.
• Updated preauthorization drug lists so they contain only medications requiring review through Prime Therapeutics.

Pharmacy Medical Policies

The following pharmacy medical policies were updated during the year:

• Anti-Obesity Medications.
• Biosimilar Products.
• CAR-T Cell Therapy.
• Gene Therapy Products.
• GLP-1 Receptor Agonists.
• Immune Globulin Products.
• Infusion Therapy Medications.
• Oncology Supportive Care Agents.
• Provider-Administered Specialty Drugs.
• Self-Administered Specialty Drugs.

Learn More: Pharmacy Medical Policies

Site of Service Medical Policy — Infusions and Injectables

The Site of Service Medical Policy — Infusions and Injectables helps members receive appropriate infusion and injectable therapy services in the most clinically appropriate and cost-effective setting, including doctor offices, infusion centers, and home settings when clinically appropriate.

EmblemHealth works with multiple organizations that recommend the most medically appropriate, convenient, and cost-effective site of care for eligible members.

Prior authorization requests should be submitted to Prime Therapeutics™:

• Fax: 888-656-6671
• Phone: 833-519-4548 (8 a.m. to 6 p.m., Monday through Friday)
• Online: Submit Prior Authorization Requests Through GatewayPA

Providers may request a real-time, clinical, peer-to-peer discussion during the prior authorization process. If a determination is not agreed upon, appeal rights are available.

Appeal Rights for Site of Service Denials

EmblemHealth respects the care you provide. If your preauthorization request is denied (called an adverse determination) based on our site of service policy(s), you, a member, their representative, or an attorney can appeal our determination. The appeal must be submitted within 180 days of the date of the adverse determination.  

You can mail or fax the appeal to the address(es) or number(s) listed below as applicable:

Site of Service Medical Policy – Infusions and Injectables Policy

By phone: 888-447-8175

By mail:
EmblemHealth Plan, Inc.
Grievance and Appeals Unit
P.O. Box 2844
New York, NY 10116-2844

By fax: 866-350-2168

Learn More: Site of Service Medical Policy – Infusions and Injectables

See Full Story: Policy Updates That Impact Where Members Get Care

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

Here is a sample of what you can find there: 

• HIV/AIDS education. 
• 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.  
• LGBTQ+ education.

 HIV/AIDS and Sexually Transmitted Diseases

Pri-Med offers HIV/AIDS and sexually transmitted infection (STI) education courses such as HIV 101: Integrating HIV Care and Prevention into Primary Care. To locate these courses, select “HIV” from the “Topic” drop-down menu. Create a free account to manage your Pri-Med 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. 

The Clinical Corner section of the EmblemHealth provider website is part of the EmblemHealth Provider Manual. It contains the Administrative Guidelines outlined in our provider participation agreements. 

Below is a summary of the key updates posted in 2026 and those planned for 2027. See the Pharmacy section for Pharmacy Medical Policy Updates.

Preauthorization, Medical Policy, and Utilization Management Updates

Throughout the year, providers received multiple updates related to CPT, HCPCS, and CMS code changes, preauthorization requirements, site-of-service policies, and utilization management programs.

Providing high-quality care often requires support beyond the office visit. This year, EmblemHealth expanded programs designed to help members navigate complex diagnoses, improve maternity outcomes, strengthen care coordination, and stay engaged in their care. Staying current with these requirements helps avoid claim delays and supports compliance with coverage policies.

Learn More

• EmblemHealth Preauthorization List.
• EmblemHealth Pharmacy Medical Preauthorization List.
• Medical Policies.
• Utilization Management Programs.
• Pharmacy Medical Policies.
• CPT and HCPCS New Code Updates Payment Integrity Administrative Policy.

NYCE PPO Launch

The launch of the New York City Employees PPO (NYCE PPO) plan brought significant operational changes for providers who care for City of New York employees, non-Medicare retirees, and their dependents. Throughout the year, providers received guidance on managing care for these members including their preauthorization requirements and the need to use the new, single provider portal. 

Learn More: New York City Employees PPO Plan

See Full Story: NYCE PPO Updates

Medical Policy Updates

EmblemHealth’s Medical Policies are posted in the Clinical Corner. Following are the policies that were revised in the past year:

•  Site of Service Medical Policy – Ambulatory Surgery.
• Site of Service Medical Policy – Infusions and Injectables.
• Artificial Intervertebral Disc Replacement.
• Bariatric Surgery.
• Bone Growth Stimulators.
• Clinical Trials.
• Home Health Care.
• Hospice Care.
• Hyperbaric Oxygen Therapy.
• Implantable Cardioverter Defibrillators.
• Lumbar Fusion.
• Sleep Studies and Treatment.
• Spinal Cord Stimulation.
• Total Joint Replacement.
• Transcatheter Aortic Valve Replacement (TAVR).
• Vagus Nerve Stimulation.
• Genetic Testing.
• Cardiac Rehabilitation.
• Pulmonary Rehabilitation.
• Wound Care Services.
• Behavioral Health Medical Necessity Criteria.

Site-of-Service Changes

EmblemHealth shared site-of-service requirements for certain ambulatory surgical procedures and selected infusions and injectables. Providers should continue to review applicable policies, authorization requirements, and alternative care settings to help ensure services are delivered in clinically appropriate and cost-effective locations.

Learn More

• Site of Service Medical Policy: Ambulatory Surgery.
• Site of Service Medical Policy: Infusions and Injectables.
• Notable Preauthorization Changes.
• Participating Ambulatory Surgery Centers.
• Provider Portal Sign-In Page.
• Prime Therapeutics GatewayPA Portal.

See Full Story: New Site-of-Service Rules

Support for Your Patients With Cancer

A cancer diagnosis can quickly overwhelm patients and caregivers. Even after a thorough office visit, patients may leave with unanswered questions, unmanaged symptoms, or financial, logistical, and emotional barriers that can disrupt care.

That is why EmblemHealth partners with Thyme Care. This program extends and reinforces your practice’s care between visits by providing oncology-trained nurses and licensed social workers who can:

• Reinforce your care plan and answer questions between visits.
• Monitor symptoms and escalate concerns early.
• Coordinate care and address barriers that impact adherence.

Learn More

• Refer a Patient to Thyme Care.
• Thyme Care Information for Primary Care Providers.

Referral Information

• Online referral: thymecare.com/referapatient.
• Email: careteam@thymecare.health.
• Phone: 201-526-8484.

See Full Story: Support for Your Patients With Cancer

Supporting Maternal Health Through Doula Services

EmblemHealth partnered with Mae Health to provide eligible Medicaid and HARP members access to care from community-based doulas and digital pregnancy support. Mae Health matches members with experienced doulas and provides resources throughout pregnancy and up to 12 months postpartum.

Participating members may receive:

• Pregnancy and fetal-development tracking.
• Educational content and support resources.
• One-on-one guidance from experienced doulas.
• Ongoing support before, during, and after delivery.

Learn More

• Mae Health Pregnancy Support Program.
• Information for Doulas Interested in Participating.

See Full Story: Pregnancy and Doula Support for Medicaid and HARP Members

Participating Laboratory Requirements

Using a participating laboratory helps members receive covered services and avoid unnecessary administrative issues. EmblemHealth continues to maintain provider contracts with Quest Diagnostics, Labcorp, and others.

• Learn More: Participating Laboratory Services for EmblemHealth Members

Laboratory Contacts

• Quest Diagnostics: 866-697-8378.
• Labcorp: By phone at 888-522-2677 or email at nenewaccounts@labcorp.com.

See Full Story: Importance of Using Participating Laboratories

Optum Spine, Pain, and Joint Portal

Providers participating in applicable Spine Surgery and Pain Management programs transitioned from the OrthoNet portal to Optum’s Spine, Pain, and Joint portal. Providers should continue using the Optum platform for applicable authorizations and correspondence.

Learn More: Spine Surgery and Pain Management Therapies Program

Provider Support: Optum Health Services: 844-504-8091, 9 a.m. to 6 p.m., Monday through Friday

See Full Story: New OrthoNet Spine, Pain, and Joint Portal

HIV/AIDS Awareness and Prevention

Throughout the year, providers were encouraged to support HIV testing, prevention, education, and linkage-to-care services through initiatives tied to World AIDS Day and National HIV Testing Day.

Learn More

• EmblemHealth HIV/AIDS Care Management Program.
• HIV Resources and Support.
• PrEP Clinical Guidelines for Healthcare Providers.
• CDC HIV Prevention Campaign Resources.
• New York State HIV Provider Directory.

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 January 2026.

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.

We partner with Carelon to provide and manage mental health and substance use services. To find a provider for your EmblemHealth members, use our Find Care tool.

For full information about our mental health and substance use services available to your patients, see:

• The Behavioral Health chapter of the EmblemHealth Provider Manual.
• The Behavioral Health and Substance Use page in Clinical Corner.
• Behavioral Health Clinical Practice Guidelines.
• Domestic Violence Guidelines.
• Children’s Medicaid Health and Behavioral Health System Transformation.

Required Training for Mental Health and Substance Abuse 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. See the NYS OASAS Training Catalog for a list of OASAS-approved trainers.
2. Two Uniform Network Provider Training modules. View these training modules through the Center for Practice Innovations (CPI) Learning Community.
   

Managing Claims Payments and Reconciliation

This year brought new tools, resources, and policy updates designed to help providers better manage payments, understand claim activity, and prepare for audits.

Provider Portal Offset Reports

New offset reports were added to the provider portal to help practices more easily identify overpayments, offsets, and recoupments. These reports provide greater visibility into payment adjustments and can help simplify account reconciliation.

Risk Adjustment Data Validation (RADV) Audits

CMS Risk Adjustment Data Validation (RADV) audits continued to highlight the importance of timely, complete, and accurate medical record documentation. Providers may be asked to submit medical records to support risk-adjustment reporting and compliance requirements. Accurate documentation remains essential for audit readiness, quality reporting, regulatory compliance, and risk-adjustment activities.

Reimbursement and Payment Integrity Policies

Throughout the year, EmblemHealth updated its Reimbursement Policies, Payment Integrity Policies, and related claims administration guidance. Providers should continue to review policy updates and effective dates to ensure billing, coding, documentation, and reimbursement practices remain current.

Reimbursement policy updates

Reimbursement policy activity during the year included updates to:

• Ambulatory Surgical Groupers.
• Assistant Surgeon Services.
• Bilateral Procedures.
• Bundled Services.
• Chiropractic Care Services.
• Coding Edits Policy.
• Daily Maximum Units.
• Discarded Drugs/Biologicals – Modifiers JW and JZ.
• Discontinued Procedures/Reduced Services.
• Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).
• Evaluation and Management Services.
• Facility Transfer – Commercial.
• Facility Transfer – Medicare and Medicaid.
• Hospital Readmissions.
• Laboratory Services – Laboratory Benefit Management Program, including:
  • Allergen Testing.
  • Biomarker Testing for Autoimmune Rheumatic Disease.
  • Biomarkers for Myocardial Infarction and Chronic Heart Failure.
  • Cardiovascular Disease Risk Assessment.
  • Colorectal Cancer Screening.
  • Coronavirus Testing in the Outpatient Setting.
  • Diabetes Mellitus Testing.
  • Diagnosis of Idiopathic Environmental Intolerance.
  • Diagnosis of Vaginitis.
  • Diagnostic Testing of Common Sexually Transmitted Infections.
  • Diagnostic Testing of Iron Homeostasis and Metabolism.
  • Epithelial Cell Cytology in Breast Cancer Risk Assessment.
  • Evaluation of Dry Eyes Testing.
  • Flow Cytometry.
  • Folate Testing.
  • Gamma-Glutamyl Transferase Testing.
  • General Inflammation Testing.
  • Helicobacter Pylori Testing.
  • Hepatitis Testing.
  • Human Immunodeficiency Virus (HIV) Testing.
  • Identification of Microorganisms Using Nucleic Acid Probes.
  • Immune Cell Function Assays.
  • Immunohistochemistry.
  • Lyme Disease Testing.
  • Micronutrient Testing.
  • Nerve Fiber Density Testing.
  • Onychomycosis Testing.
  • Oral Cancer Screening and Testing.
  • Pancreatic Enzyme Testing for Acute Pancreatitis.
  • Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing.
  • Pathogen Panel Testing.
  • Pediatric Preventive Screening.
  • Prenatal Screening (Nongenetic).
  • Prescription Medication and Illicit Drug Testing in the Outpatient Setting.
  • Prostate-Specific Antigen (PSA) Testing.
  • Salivary Hormone Testing.
  • Serum Testing for Evidence of Mild Traumatic Brain Injury.
  • Serum Tumor Markers for Malignancies.
  • Testing for Alpha-1 Antitrypsin Deficiency.
  • Testing of Homocysteine Metabolism-Related Conditions.
  • Testosterone Testing.
  • Therapeutic Drug Monitoring for 5-Fluorouracil.
  • Thyroid Disease Testing.
  • Urinary Tumor Markers for Bladder Cancer.
  • Urine Culture Testing for Bacteria.
  • Venous and Arterial Thrombosis Risk Testing.
  • Vitamin B12 and Methylmalonic Acid Testing.
  • Vitamin D Testing.
• Medicaid NYRx Pharmacy.
• Modifier Reference Policy.
• Multiple Procedure Payment Reduction.
• National Drug Code (NDC) Requirements for Drug Claims.
• No Cost/Reduced Cost Drugs, Implants, and Devices.
• Nutritional Counseling Services.
• Observation Services.
• Obstetrical Services.
• Preventive Care Services (Commercial and Medicaid).
• Preventive Care Services (Medicare).
• Preventive Medicine and Screening (Commercial).
• Prolonged Services.
• Radiopharmaceuticals and Contrast Media.
• Telehealth and Virtual Care Services.
• Vaccines and Immunization Administration Services.
• Venipuncture Services.

See all Reimbursement Policies.

Payment integrity policy updates

Payment integrity policy activity during the year included updates to:

• Annual Fee Schedule Updates – CMS and Medicaid.
• Claim Review Program.
• Device, Implant, and Skin Substitute Coding Guidelines for Facilities.
• Medicaid State Directed Payments and Benchmark Rate Adjustments.

See all Payment Integrity Policies.

EFT and ERA Through PNC ECHO

Electronic funds transfer (EFT) and electronic remittance advice (ERA) through PNC ECHO can help practices streamline payment processing, improve reconciliation, reduce paper transactions, and decrease administrative workload. Practices that have not yet enrolled should adopt these tools to simplify payment administration. Go to ECHO’s site to enroll.

Learn More: Use One System for All Payments With PNC ECHO