Please click here for our COVID-19 Vaccine and Monoclonal Antibody Infusions Reimbursement Policy - Revised August 2021.
During the COVID-19 State of Emergency, EmblemHealth will follow CMS guidance and waive the requirement that Medicare Advantage members obtain a primary care physician referral to receive specialist services.
No Member Responsibility for Personal Protective Equipment (PPE) Costs
According to New York State Department of Financial Services (DFS) Insurance Circular Letter No. 14 (2020), participating providers may not charge EmblemHealth members in our Commercial plans for COVID-19-related provider expenses, including sanitizing exam rooms and using personal protective equipment (PPE) such as masks, gowns, and gloves. Any money collected from members for PPE must be returned to the member. DFS has asked insurers to report back on:
- Member(s) impacted
- Total refunded to member(s)
- A description of how refunds will be provided
If you charged any EmblemHealth member(s) for PPE, please complete and return this form to us for all affected members no later than October 30, 2020. Note that this directive does not affect applicable member cost-sharing for the underlying visit or health care service.
Additionally, the New York State Department of Health says, “the Medicaid program prohibits enrolled providers from billing recipients for charges for COVID-19 protective measures, including sanitizing exam rooms and using personal protective equipment, such as masks, gowns, and gloves (collectively, "PPE"). Cost sharing for Medicaid fee-for-service and managed care members is limited to applicable copays based on federal rules, including the New York's Medicaid State Plan and 1115 Medicaid Redesign Team Waiver. Billing Medicaid recipients for PPE is considered an ‘Unacceptable Practice’ under Medicaid rules, which may result in provider sanctions up to and including termination from the Medicaid program.”
UPDATE: No COVID-19 Member Cost-Sharing
At this time, EmblemHealth members across all product lines will have no cost-sharing (including copayments, coinsurance, or deductibles) for the diagnostic visit and related lab test for the coronavirus (COVID-19).
As state and federal guidelines evolve in response to the pandemic, EmblemHealth will continue to evaluate the latest guidance and make appropriate adjustments to our policies. We will also continue to carefully monitor utilization in support of our members’ diagnostic needs, while upholding our commitment to detecting, correcting and preventing fraud, waste and abuse. This is essential to maintaining a health care system that is affordable for everyone.
(June 21, 2021) We have published COVID-19 Billing Guidelines for our Commercial and Medicare Advantage Lines of Business. Please click here for that guide.
Medicare Advantage and the CARES Act
EmblemHealth will follow Medicare guidelines in the federal coronavirus (COVID-19) stimulus bill (known as the “CARES Act”) to:
- Add 20 percent to inpatient DRG weighting factor portion of the facility reimbursement for both in-network and out-of-network COVID-19 care given to Medicare Advantage members.
- Effective with admissions occurring on or after Sept. 1, 2020, claims eligible for the 20 percent increase in the MS-DRG weighting factor will also be required to have a positive COVID-19 laboratory test documented in the patient’s medical record. Positive tests must be demonstrated using only the results of viral testing (i.e., molecular or antigen), consistent with CDC guidelines. The test may be performed either during the hospital admission or no less than 14 days prior to the hospital admission.
Adding 20 percent to COVID-19 inpatient reimbursement
In accordance with Centers for Medicare & Medicaid Services (CMS) methodology, EmblemHealth will add 20 percent to the MS-DRG-based inpatient reimbursement (operating component only) for Medicare Advantage patients who were discharged with COVID-19 diagnosis code B97.29 on or after Jan. 27, 2020 and on or before March 31, 2020 or with diagnosis code U07.1 on or after April 1, 2020 through the duration of the COVID-19 public health emergency period.
Effective with Sept. 1, 2020 admission dates, CMS requires that a positive viral COVID-19 test result be documented in the medical record for inpatient claims to be eligible for the 20 percent increase.
Effective for all out-of-network and in-network hospitals
- Inpatient admission MS-DRG claims having COVID-19 as the primary diagnosis, as designated by U071.1 will process with the COVID Add-On. We may audit paid claims, and we may ask the hospital to provide medical records to validate the presence of a positive COVID-19 test.
- Inpatient admission MS-DRG claims where COVID-19 was not the primary diagnosis for the admission, but COVID-19 was a secondary or subsequent diagnosis, will initially process without the COVID19 add-on payment.
- Claims will process with a remittance message informing the facility that, if the COVID-19 DRG add-on payment is warranted, the provider is to submit medical records validating the documentation of a positive COVID-19 lab test within 14 days of the admission date.
- The claim will be adjusted to pay the COVID-19 add-on amount once EmblemHealth validates an eligible positive COVID-19 test.
Temporary suspension of the Medicare sequestration fee
The suspension of the 2 percent Medicare sequestration fee for in-network providers will continue through the end of 2021 after President Joseph Biden signed legislation covering this fee suspension.
(Update: May 6, 2021) The following telehealth rules reflect current guidance from the New York State Department of Financial Services:
Our Temporary Telehealth Policy, with allowable procedure codes, and Frequently Asked Questions provides guidance on these services for our members. Telehealth services include visits by phone, virtual check-in, or virtual visit via Skype, FaceTime, or other video exchange.
- EmblemHealth members in our commercial line of business will have no cost sharing (including copayments, coinsurance, or deductibles) for in-network telehealth visits conducted through June 4, 2021.
- Members with a benefit plan that includes the Teladoc™ program will have no cost-sharing for Teladoc visits through June 4, 2021. There are two exceptions:
- The $0 cost-sharing waiver for Medicare plans ended Dec. 31, 2020.
- The $0 cost-sharing waiver for ASO plans ended on Sept. 9 2020.
- The telehealth cost-sharing waiver may not apply to ASO plans.
- On Sept. 9, the telehealth waiver expired for our Medicare line of business. You may begin collecting member cost shares for dates of service beginning Sept. 10.
Click here to learn how you can use Telehealth to close gaps in care and get the data needed for commercial, Medicaid, and Medicare Advantage health plan risk adjustment programs.
UM and Emergency Admission Notifications
(Jan. 13, 2022) COVID-19 Alert: Suspension of Utilization Review Requirements for Inpatient Transfer Discharges
(February 22, 2021) The temporary suspension of preauthorization for certain inpatient admissions, transfers and discharges required by the New York State Department of Financial Services’ Circular Letter 17 has expired.
Beginning today, all preauthorization requirements for the following areas have been restored: Inpatient admissions, hospital transfers, and inpatient discharges to inpatient rehabilitation, skilled nursing facilities, home health care, or inpatient behavioral health facilities. Please refer to our Provider Manual and our UM and Medical Management page for guidance.
As always, we are committed to collaborating with our hospital and facility partners to ensure our members receive the care they need.
To address the high demand for COVID-19 testing, EmblemHealth is providing additional lab options. Quest Diagnostics is EmblemHealth’s preferred, in-network lab.
|Northwell Health Laboratories||Use CPT code 87635||516-719-1100|
|LabCorp||Use test code 139900
Use CPT code 87635
|Bio-Reference||Use CPT code 87635||833-684-0508|
If you send a specimen to a lab other than Quest, or have any collection or billing questions, please contact them at phone number above. While some of these additional labs are normally out-of-network for EmblemHealth members, we know partnering with you and providing expanded access to testing is in everyone’s best interests.
EmblemHealth does not require preauthorization for COVID-19 testing.
Screening and Coding Guidance
- Providers should make sure to follow Centers for Disease Control and Prevention (CDC) guidelines.
- New York State issued a special update on the Department of Health website: Medicaid Coverage and Reimbursement Policy for Services Related to Coronavirus Disease 2019 (COVID–19). The state’s public information page includes daily updates and additional guidance. Providers in other states should seek out guidance from their state departments of health.
- The CDC published the ICD-10-CM Official Coding Guideline with links to official diagnosis coding guidance for health care encounters and deaths related to COVID-19.
- Update (Aug. 21, 2020): The New York State Department of Health has issued coding guidance for Pharmacies engaged in COVID-19 testing Medicaid recipients, including our Medicaid and HARP members.
- (Update: Sept. 29, 2020): In accordance with State and Federal regulations, EmblemHealth is waiving members’ cost-share for COVID-19 testing as well as the diagnostic visit associated with testing. Please click here for our policy.
- (Update: Oct. 23, 2020): EmblemHealth is clarifying coding guidance for Pharmacies engaged in COVID-19 testing and specimen collection for members who are enrolled in commercial plans.
Members may also have questions about their prescription coverage and having enough maintenance medication on hand. This provider update includes information we emailed to our members on March 10.
Use our secure provider portal or fax. See this link for more information.
- Electronically submit claims for faster processing.
- Sign in to your secure portal account and make sure we have the correct email for you and your practice. If you don’t have a portal account, here is a guide for setting up your account.
- EmblemHealth is providing tips and updates to its members and the public. We are regularly updating this information and posting it here. The page includes accurate, fact-based information from our medical leadership as well as city, state, and federal authorities. Feel free to share this link with your patients.
- Centers for Medicare & Medicaid Services News Alert for March 26.
- New York State has published COVID-19 Guidance for Medicaid Providers. The state has also published Special Editions of their Monthly Medicaid Updates; here are the March and April issues.
- The New York City Department of Health hosted a webinar on how community health centers and independent practices can be authorized to enroll patients with COVID-19 in the COVID-19 Hotels Program sponsored by the City of New York. To view a recording of the 35-minute webinar, click here.
- Click here for a letter we sent to all in-network providers at the start of the COVID-19 emergency in March 2020.
- On Sept. 10, 2021, the U.S. Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), announced new funding available for health care providers affected by the COVID-19 pandemic. The HHS application is available on the HRSA website.