August 2019 In The Know


New site of service pre-authorization list

We want to remind you that September 1 is the new start date for HIP’s commercial and Medicaid supplemental pre-authorization rules for specific sites of service. Click here for more details.

Bridge Network members and new claims payment process

EmblemHealth is expanding its offerings and bringing new patients to your office. Starting September 1, you may begin to see the words “Bridge” or “Bridge Network” on some EmblemHealth or ConnectiCare member ID cards. These members belong to self-funded employer groups (administrative services only/ASO). For more information, click here.

Infertility benefits changing October 1 for Medicaid; January 1 for commercial members

New York State has mandated changes for infertility benefits for our Medicaid and commercial members. Effective October 1, 2019, changes for Medicaid are limited to female infertility and offers certain drug coverage. Commercial benefits, effective January 1, 2020, also cover additional services and the male population but have no drug coverage. For details about infertility and the state's demonstration project, see DOH website.

New referral and approval formats introduced with system changes

As EmblemHealth continues to upgrade its technology in the coming months, you will see new numbering formats for our referral and preauthorization transactions.

These transactions will have nine-digits and will be made up of numbers only.

  • On September 1, 2019, AdvantageCare Physicians will introduce “easy referrals” with the new numbering format.
  • Later this year, referrals and preauthorizations for EmblemHealth network providers will use the new numbering format.

These new formats are valid numbers that our claims systems will recognize.

There will be a transition period when the old numbers will be honored.

Here are the three types of referral numbers that you will see in the coming months.

Referral number formats Samples
The letters PF followed by 12 numbers F997210789217
The letters QF followed by 12 numbers QF997210903217
New: nine numbers only 002008078

Non-city of NY GHI PPO member changes start October 1, 2019

GHI PPO members (other than City of New York) will begin migrating to our new claims platform on October 1. Transitions will take place upon plan renewal. Please ask your patients for their current member ID card at each appointment. Please submit pre-authorization requests and claims using the applicable member ID that is in effect on the date of service. The following changes will apply once members are on the new system:


Reducing HPV-related cancers

EmblemHealth is collaborating with the American Cancer Society, New York State and City Departments of Health, and other New York State health plans to encourage more providers to recommend the HPV vaccine to help reduce the rate of HPV-related cancers. The letter, jointly developed as part of this collaboration, explains what you can do to keep our members healthy for a lifetime. Also, review these materials that can help you and your practice deliver strong and effective recommendations for the HPV vaccination series.


The Claims Corner section of our provider website is a rich resource of information that helps your practice navigate EmblemHealth claims and billing processes. See new payment policies for electroencephalogram (EEG) and evaluation management services with pulmonary diagnostic procedures.


Increasing colorectal cancer screening rates

We are working with Quest Diagnostics on a program aimed at increasing colorectal cancer screening rates for our members. Selected Medicare and Medicaid members will receive an outreach phone call from us offering an InSure® ONE™ collection kit. Primary care providers will be sent test results for inclusion in the members’ medical records and for follow-up action as medically appropriate.

Medical Policy Updates

To see the latest updates click here.

Medical technologies database updated July 2019

To see the latest updates, click here.


EmblemHealth updates its Formulary on a regular basis. Find our most recent updates here here.


Required SNP MOC training coming soon

The annual training for Special Needs Plan (SNP) Model of Care (MOC) will launch soon. The training is required for providers who participate in the VIP Prime Network. Look for our notice to arrive via email, fax, and postal mail. The communication will include the user ID and PIN number needed for this required training.

New to EmblemHealth? Join us on September 11 for our monthly webinar for practitioners and office staff

This webinar provides an overview of our products and benefit plans, special utilization management programs, and how to navigate our provider portal. Sign up for our next webinar on September 11, 2019 at 10 to 11 a.m. or 2 to 3 p.m. Space is limited, Register today.

HIV/AIDS resources for members and courses for providers

Please take advantage of the HIV/AIDS resources we have posted on our provider portal for you to share with your patients. To refer a patient to the EmblemHealth HIV Case Management program, please call or have the member call 1-800-447-0768.

You can also take advantage of free CME activities sponsored by Pri-Med. They offer 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.

Medicaid: New York State Medicaid Update

We are happy to share with you the newest issue of Medicaid Update, a monthly publication from the Office of Health Insurance Programs of the New York State Department of Health. The July edition includes:

Pharmacy Update

Policy and Billing Guidance All Providers If you missed a previous issue, or just want to review their archive, please visit the DOH Medicaid Update page.

Review your directory information today

See video on how to make updates to your directory information. If you are leaving a service location, please notify us as soon as possible so we can support you and your patients with appropriate transitions of care.
Provider Update
eNews Policy Update