Claims Submission and Utilization Management for SOMOS Community Care

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Claims Submission and Utilization Management for SOMOS Community Care


Update 4/12/2021: Referrals Waived For SOMOS-Managed Members


Retroactive to Dec. 1, 2020, the referral requirement for SOMOS-managed members has been eliminated for participating EmblemHealth providers. Specialists’ claims with dates of service on or after Dec. 1 will not deny for a missing referral. See our Quick Guide for plans that need referrals.


Date Issued: 10/22/2020

Starting Oct. 1, 2020, EmblemHealth providers may see “SOMOS” on the front of some Medicaid, HARP, CHPlus, and Essential Plan members’ ID cards. These members are assigned to a SOMOS Community Care (IPA) primary care physician. SOMOS is the managing entity responsible for conducting most utilization management and claims processing for their assigned members.


Providers need to follow SOMOS’ preauthorization and claims submission processes when treating members assigned to SOMOS. Make sure you check the back of the member ID card for this information. Preauthorization and claims contacts for SOMOS are also listed in the Directory chapter of the Provider Manual. To set up a SOMOS account, go to: SOMOS Portal.


SOMOS members participate in our vendor-managed utilization management programs. Delegated vendors should continue to follow their currently established processes. Hospitals should continue to submit ER Admission Notifications on