February 2020 In The Know


Novel Coronavirus Officially Renamed COVID-19

The Centers for Disease Control and Prevention (CDC) is closely monitoring the outbreak of the 2019 Novel Coronavirus recently renamed COVID-19 by the World Health Organization (WHO).

The CDC has published a flowchart for health professionals to help identify and assess patients who may have COVID-19. Health care workers caring for patients with confirmed or possible COVID-19 should exercise extreme caution and adhere to CDC recommendations for infection prevention and control. We encourage you to regularly check the CDC website for the latest updates.

We have also posted information on emblemhealth.com to educate our members.

New Medicare Site of Service Requirements Feb. 1

New Site of Service requirements for our Medicare members started Feb. 1. See the UM and Medical Management page of Clinical Corner on our provider website for details.

Make sure your staff knows which of our networks you participate in for 2020. Current participation can be found in your Practice/Provider Profile on our provider portal under your applicable EmblemHealth user IDs.

Reminder: EmblemHealth PPO Member Transition – New “K” IDs and New Programs

Over the course of the year, our EmblemHealth PPO membership is transitioning to a new system that will allow us to apply consistent rules and programs. Upon plan renewal, members will be given new member IDs and be subject to new administrative requirements as follows:

  Pre-Transition Post-Transition
Member ID Number 11-digits & all numeric 11-digits & alphanumeric starting with “K”
Preauthorizations Web portal: emblemhealth.com Phone: 866-447-9717
Radiation Therapy Preauthorization N/A Contact eviCore for preauthorization at: Web portal (preferred method): evicore.com Phone: 800-835-7064 or 866-889-8056 Fax: 800-540-2406
Cardiology Imaging Preauthorization N/A Contact eviCore for preauthorization at: Web portal (preferred method): evicore.com Phone: 800-835-7064 or 866-889-8056 Fax: 800-540-2406
Radiology Privileging Radiology Privileging Program Outpatient Imaging Self-Referral Payment Policy (SRPP)
Behavioral Health Claims Processed by EmblemHealth Processed by Beacon Health Options

ASO Bridge

Since we launched our ASO Bridge in September, EmblemHealth represents* six insurance companies and one Independent Practice Association (IPA) — EmblemHealth Network Services, IPA (HNSIPA).

EmblemHealth also underwrites EPO/PPO. Our new ASO Bridge uses an EPO model. 

EmblemHealth-only providers are considered in-network for ASO Bridge even if not explicitly shown on the ID card or on the provider portal.

*Click here to see a full list of companies, lines of business, networks, and benefit plans for 2020.

Medicaid National Diabetes Prevention Program (NDPP)

As of Feb. 1, 2020, EmblemHealth covers diabetes prevention services through the National Diabetes Prevention Program (NDPP). This benefit covers 22 NDPP group training sessions over the course of 12 months.


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.

Reminder: The EmblemHealth timely filing time frame is 120 days unless the participation agreement states an alternative time frame should be applied.


Reminder: NYSDOH Opioid Treatment Plan Requirements

The New York State Department of Health (NYSDOH) notified providers in a letter dated Feb. 13, 2019, of a new Public Health Law about prescribing opioids.

The law requires that a written treatment plan be part of the patient’s medical record if a practitioner prescribes opioids for pain lasting more than three months or past normal tissue-healing time. The law was effective April 1, 2018 and amends Public Health Law §3331.

Exceptions include patients who are being treated for:

  • cancer that is not in remission;
  • hospice or another end-of-life care; and
  • palliative care.
Learn more.

A resource to assist you in developing interventions for the required Opioid Treatment Plan may be found on the Centers for Disease Control and Prevention (CDC) website and is called CDC Pocket Guide: Tapering Opioids for Chronic Pain.

New York State Department of Health (NYSDOH) 2019-2020 KIDS Quality Performance Improvement Project (PIP)

EmblemHealth has launched a campaign to support our commitment to increasing the quality and efficiency of pediatric screenings for children within their first 1,000 days of life. As part of this initiative, you may receive a copy of our comprehensive early screening pocket reference guide, “The First 1,000 Days” in the mail.

This reference guide provides information on early identification, prevention, diagnosis, treatment, intervention, and follow-up care for lead exposure, newborn hearing loss, and developmental disorders. You may also access this valuable practice resource on our website.

Remind Your Patients to Get Their Flu Vaccine

According to the Centers for Disease Control and Prevention (CDC), flu activity usually peaks between December and February. So now is a key time to remind your patients that although they may have received a flu vaccine last year, the flu virus changes each year and a new vaccine is needed. Speak with your patients about 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.

February is American Heart Month

In February, we take time to recognize and reflect on the conditions, diseases, and habits that impact the heart. Click here for more information on lifestyle choices and other ways to prevent and combat heart disease, leading to a long, healthy life for both you and your patients.

In March, we will observe National Endometriosis Awareness Month, and International HPV Awareness Day is on March 4, so be on the lookout for more information.

Updated Clinical Practice Guidelines (CPGs)

The following Clinical practice guidelines have been updated and are available on our website.
  • Helicobacter pylori
  • Lead Screening
  • Lyme Disease
  • Osteoporosis
  • Pediatric and Adolescent Preventive Services
  • Rheumatoid Arthritis
  • Sexually Transmitted Diseases (including recommendations for HPV vaccination)
  • Smoking Cessation

Medical Policy Updates

All Medical Policies are available for download in Clinical Corner on our provider website. The Medicare line of business has been added to Site of Service policy effective Feb. 1, 2020.

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.

Reminder: Accredo’s Convenient Care Program Starting April 1, 2020

EmblemHealth is partnering with Accredo Specialty Pharmacy to provide home infusion treatments in the member’s home through Accredo’s Convenient Care Program. More.


Join us March 11 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 March 11, from 10 to 11 a.m. or 2 to 3 p.m. Space is limited, Register today.

Keep Your Directory Information Current

If a provider in your practice is leaving, please inform us as soon as possible using the form provided at https://www.emblemhealth.com/providers/resources/toolkit/reminder-keep-your-directory-data-current. To report other changes, you can also sign in to your Provider/Practice Profile on our secure website, https://www.emblemhealth.com/providers/resources/provider-sign-in. If you participate with us under a delegated credentialing agreement, please have your administrator submit these changes.

Follow Access and Availability Standards

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. You may also download it here. Refer to it often and share it with appointment schedulers.

Do Not Bill Dual Eligible Members for Any Medicare Balance Due

If Medicare-Medicaid dual eligible individuals have their Part A and Part B cost-share covered by their Medicaid plan, they are not responsible for their Medicare Advantage cost-share for covered services. Please do not balance bill these members for Medicare deductibles, coinsurance, or copayments. If you received Medicare and Medicaid payments for services given to these members, it must be accepted as payment in full.

Use Network Labs

Quest Diagnostics and its affiliate, AmeriPath, are our preferred labs. Data from out-of-network testing is not available to EmblemHealth for our disease management programs. This may result in inaccurate reporting and the possibility of practitioners and/or members being told a test is needed when it may have already been done.

To keep costs down for our members, please refer all of your EmblemHealth members to Quest Diagnostics, AmeriPath, or another participating laboratory in accordance with your Agreement with us. If you do not have an account, call:

  • Quest Diagnostics at 866-697-8378, (select option 1, then option 8)
  • AmeriPath at 800-553-6621 for dermatopathology services
  • AmeriPath at 866-436-9631 for hematopathology, cytogenetics, gastroenterology and urology services


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