December 2019 In The Know


EmblemHealth Reduces Preauthorization Requirements

EmblemHealth has a mission to create healthier futures for our members and communities. We fulfill that mission by working closely with providers who deliver care. This collaboration informs everything we do.

Therefore, beginning Jan. 1, 2020, we are significantly reducing the number of procedure codes that need our approval before delivering care. This will help members quickly and efficiently receive the care they need. This change affects members in all our plans, including Medicaid managed care, Medicare Advantage, coverage offered through employers, and Individual plans in the Marketplace.

For our providers, this will allow them to fully devote their attention to providing the care people deserve. The change is based on national treatment standards developed by physicians and other medical professionals that establish best practices for ensuring people receive high-quality, affordable care and that science leads our decision-making. We also feel it is the right thing to do.

For additional information, including links to the lists of preauthorization codes in effect as of Jan. 1, 2020, click here. A list of codes we will remove on Jan. 1, 2020 for our Medicare, Medicaid, and Commercial lines of business can be found here. Read more.

NYS Law for Infertility Treatment Effective Jan. 1

New York State recently passed legislation that requires insurers such as EmblemHealth to update the infertility services coverage they provide to members as policies issue, renew or are amended on and after Jan. 1, 2020.

EmblemHealth will comply with the state mandate for in-vitro fertilization (IVF) and fertility preservation by adding five new CPT codes to our revised 2020 preauthorization list; five CPT codes will also be removed from this list. The in-vitro fertilization (IVF) law requires large group medical plans to cover three cycles of IVF used in the treatment of infertility. The fertility preservation law requires individual, small, and large group insurance policies or contracts to provide coverage of fertility preservation services for iatrogenic infertility.

Click here to learn more.

2020 Networks & Benefit Plans

In 2020, EmblemHealth is introducing new networks and plans as well as expanded service areas for Medicare and Medicaid members. See all of the changes in our 2020 Networks and Benefits table. Our 2020 Networks and Benefit Plans guide will be posted online in early January.

Medicare Advantage in 2020

We are excited to introduce our suite of Medicare Advantage products for 2020. Benefit changes include a new EmblemHealth Medicare Connect Concierge service. The Medicare 2020 guide will be posted on our website in early January to give you quick access to important contacts and operational rules.

Starting Jan. 1, we will update our preauthorization lists (see preauthorization article above), including one that is Medicare-specific. Please check the front of member ID cards for the network (VIP Prime or Medicare Choice PPO), the benefit plan, applicable copayments, and managing entity, and the back of the card for utilization management and claims submission information. Many plans do not require referrals; you should have received our quarterly fax with a listing of the plans that do not need a referral.

Please note: Montefiore CMO will not manage Medicare members starting Jan. 1, 2020.

For more information about our Medicare plans for 2020, please click here to visit our dedicated network and benefit plan page.

Open enrollment for New York State Marketplace ends Jan. 31, 2020

During open enrollment, individuals and small groups may enroll in a health plan through the New York State Marketplace.


Medicaid: New York State Medicaid Update

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

Keep Your Directory Information Current

Remember to keep your directory information up to date so patients can find you. Review and make changes to your profile by following the process outlined in the Network and Benefit Plans chapter of the Provider Manual.

Follow Access and Availability Standards

It’s important for our members to get the right care at the right time. See our Appointment Availability Standards During Office Hours & After Office Hours Access Standards brochure available on the Provider Toolkit in the Provider Resources section of our provider website. Refer to it often and share it with appointment schedulers.


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.


Remind your patients to get their flu vaccine

As you know the flu vaccine is the best way to prevent this common but serious respiratory infection. Remind your patients that although they received a flu vaccine last year, the flu virus changes each year and a new vaccine is needed. Speak with your patients about the vaccine safety and minor effects such as injection site tenderness which may occur. Please remember if the vaccine is the only reason for the office visit then no copayment is collected. If your office does not carry the vaccine direct your patients to their local pharmacy.

Medical policy updates

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

Medical technologies database

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


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


Join us Jan. 8 for our monthly webinar

Practitioners and office staff are welcome to join our monthly webinar that 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 session to be held Jan. 8 from 10 to 11 a.m. or 2 to 3 p.m. Space is limited. Register today.
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