August 2020 In The Know


COVID-19 UPDATE: No Member Responsibility for Personal Protection Equipment (PPE)

According to New York State Department of Financial Services guidance, providers may not charge EmblemHealth members in our Commercial or Medicaid 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. Additionally, the New York State Department of Health says, “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.”

REMINDER: Electronic Preauthorization Through ESI for Pharmacy

As previously announced, Express Scripts (ESI) is now performing utilization management services for most drugs for all Commercial and Health Exchange EmblemHealth plan members. This change was effective Aug. 3.

The services include preauthorizations, quantity limits, and step therapy. This new online process is fast, secure, and simple, and reduces the administrative burden that comes with getting your patients the medications they need.

Click here for the announcement letter we sent to all providers.

Health Outcomes Survey (HOS) and Your Medicare Advantage Patients

CMS is currently administering the Health Outcomes Survey (HOS) to a random sample of Medicare Advantage Members. The survey is intended to assess a health plan’s ability to maintain or improve a member’s physical and mental health over time.

The same members will be surveyed again in two years. Members will be asked to evaluate their own health and recall the discussions they have had with their doctors. Your interactions with our Medicare members to improve their outcomes will also influence the results. Learn More

Concurrent Review (DRG Inpatient Stays)

For inpatient stays after July 20, 2020 that fall under a diagnosis-related group (DRG) payment system, facilities only need to provide clinical information to the managing entity (EmblemHealth, Montefiore, or HealthCare Partners) for the initial length of stay and for discharge planning unless outlier payments are expected or other special circumstances exist. For details, see the Utilization and Care Management chapter of the EmblemHealth Provider Manual and review the Hospital and Facility Procedures section.

Simplified Referral Transactions

In response to feedback from our providers and provider portal users, we evaluated our referral process to make it easier for our primary care providers (PCPs) to refer members to specialists. Specifically, we simplified the portal transaction to reduce time spent on referrals. Here are the updates:

  • Fewer data entry steps.
  • Dialysis no longer requires a referral.
  • Referrals may be back-dated up to 30 days.

We thank the providers and portal users who contributed feedback to this effort!

Use Provider Portal to See GHI Preauthorization Request Status

As of July 1, providers may view the status of preauthorization requests made on Status information is updated each night.

For GHI PPO members, who are not City of New York employees or retirees, you may use the web to request preauthorization for inpatient admissions and ambulatory surgery. For GHI PPO City of New York members, you may use the web for home health requests. For requests made by phone or fax, status may be requested by calling 866-447-9717.

Member ID Card Transition Continues

In last month’s issue, we announced that City of New York GHI PPO members and their dependents were issued new member ID cards and new member IDs using the new K-ID format. We are continuing to update our members to this new K-ID format. During this ongoing transition, other member groups may still have ID numbers that do not begin with a K. We urge you to not reject member appointments based solely on this issue. You can always check member eligibility through our provider portal or contact provider customer service if you have any concerns about a member’s eligibility.

We’re Improving Your Account Security

The security of your information and our member’s data is very important to us. This month we will be implementing a new PIN policy that will enhance security on our provider portal. You will be asked to reset and create a new PIN when you log in to your account. Click here for tips on creating a secure PIN.

Please note: Accounts will be locked after five unsuccessful login attempts, and you will then need to contact provider customer service to have your account unlocked. For added security and to better align with industry standards, we will require all users to reset their PIN every 60 days. We also encourage providers and office staff to have their own individual portal accounts rather than share a username and password.

It’s National Immunization Awareness Month – Are Your Patients Up to Date?

August is National Immunization Awareness Month (NIAM). At EmblemHealth, we believe – as research has consistently shown – that health care professionals are the most trusted sources of information to help protect patients of all ages against vaccine-preventable diseases.

We encourage you to ensure your patients receive timely inoculations. The Public Health Foundation and CDC have developed a digital communication toolkit with messages and graphics tailored to your role as a healthcare professional emphasizing the importance of vaccination for your patients.

For information about vaccination guidance during a pandemic, visit:


Dual Eligible SNP – Payment Change: Part B Drugs

As of Jan. 1, 2020, EmblemHealth no longer pays the full cost of Part B drugs. Please bill New York State Medicaid for members’ cost-share.


Medicaid: New York State Medicaid Update

The Office of Health Insurance Programs of the New York State Department of Health has posted its July Medicaid Update.


The Claims Corner section of our website is a rich source of information that helps your practice navigate EmblemHealth claims and billing processes. Please check often to see posted updates.

ECHO Health Begins Claims Payment Processing

As previously announced, ECHO Health began processing GHI payments beginning Aug. 18. HIP begins Sept. 2. If you are currently enrolled for EFT/ERA with Remittance Advantage or with CPR, no action is needed. If you have been receiving paper checks, you will be transitioned to virtual credit card payments. See the Transition Schedule and Frequently Asked Questions for details.


PT/OT Benefit Extensions for GHI EPO/PPO Non-City of New York

To request a PT/OT benefit extension for GHI EPO/PPO non-City of New York, please use the fax form process in the Provider Manual’s PT/OT chapter.

Preauthorization List for GHI City of New York Added to Clinical Corner

EmblemHealth manages professional services for GHI PPO City of New York members. While no changes have been made to the preauthorization requirements, we have moved the location of the preauthorization code list on our website. You may now find them in one convenient location on a dedicated Preauthorization List page in the UM & Medical Management section of Clinical Corner.

Updated Clinical Practice Guidelines (CPGs)

Clinical practice guidelines are updated on a regular basis. Please visit our website for the latest guidelines.

Medical Policy Updates

All Medical Policies are available for download in Clinical Corner on our provider website.

Our Temporary Telehealth policy has been updated to include National Diabetes.

Medical Technologies Database

A comprehensive listing of medical technologies reviewed by the Medical Policy Committee for coverage consideration is available for download in Clinical Corner on our provider website.


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

WINFertility (WIN) to Manage Fertility Medications for City of New York CBP Plan

Effective Aug. 7, WIN conducts utilization management of fertility medications for City of New York CBP Plan members. To request preauthorization for infertility services and fertility prescriptions, please contact WIN at 833-439-1515.


Join us Sept. 9 for our monthly webinar

The next session of our monthly webinar series will be held on Wednesday, Sept. 9 from 10 to 11 a.m., and again from 2 to 3 p.m. Practitioners and office staff are welcome to join this monthly webinar that provides an overview of our products and benefit plans, special utilization management programs, and how to navigate our provider portal. Register today as space is limited.

Cultural Competency Education Available

Cultural competency continuing education and resources are available for health care providers to improve awareness and skills in addressing the health care needs of our diverse membership. Find these programs by signing into your account on the secure provider website.

Keep Your Directory Information Current

If a provider in your practice is leaving, please inform us as soon as possible. To report other changes, you can also sign in to your Provider/Practice Profile on our secure website. If you participate with us under a delegated credentialing agreement, please have your administrator submit these changes.

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