Starting Jan. 1, 2023, to align with guidance from the New York State Department of Health (NYSDOH), EmblemHealth introduced a new Integrated Benefit Dual Program (IB-Dual Program). Under this program, EmblemHealth members enrolled in both Enhanced Care (Medicaid) or Enhanced Care Plus (HARP) and VIP Dual (HMO D-SNP) can receive their benefits all under one plan. Enrollment is done on a rolling basis. Each month new members are added to the program.
In May 2023, EmblemHealth identified a group of members who qualified for IB-Dual coverage retroactively to prior months in the year. Qualifying members were issued new IB-Dual member ID numbers and their old member ID numbers for Medicaid and D-SNP were terminated.
However, some members received services during the time period that the retroactive change covers. Claims were submitted for dates of service between Jan. 1 and May 30 and processed under their old Medicaid, HARP, or HMO D-SNP.
In order to reconcile payments so they are correctly reflected as being made as part of the IB-Dual Program, we need to reprocess the claims. To do this, we kindly require that any payments issued to providers for these members and these dates of services be refunded back to EmblemHealth. We will send a recovery letter identifying the members and claims. We will then reprocess the claims under the correct ID numbers so that payment runs through the IB-Dual Program. Unfortunately, we are not able to internally move the claim to reflect that it is through a new program and a new ID number.
Recovery and Resubmission Process
In August 2023, we sent providers new Explanations of Payment (EOPs) for the claims that EmblemHealth processed with a message saying, “Member’s benefit plan changed. These claims will process using the new member ID and will show “denied” for the old member ID.
Providers who received an EOP with this message were also sent a recovery letter identifying the affected claims, reason for the recovery request and instructions for returning the funds to us.
Claims Submitted to Montefiore CMO, Health Care Partners, and SOMOS
The retroactive change in enrollment also affects members who were assigned to one of our partners, Montefiore CMO, Health Care Partners, and SOMOS. In addition to moving these members to a new benefit plan, their Managing Entity for these members has changed to EmblemHealth. This means that providers are being asked to return payments made by their organization to them and to resubmit the claims to EmblemHealth. Montefiore CMO, Health Care Partners, and SOMOS have sent their own recovery letters requesting repayment.
IB-Dual Payment Methodology
For details on how we pay for IB-Dual claims, see the IB-Dual Reimbursement Methodology section of the EmblemHealth Provider Manual’s Claims chapter.
Note: Providers cannot balance bill any of our dual (Medicare/Medicaid) members, including those in the IB-Dual Program.
JP 63180 09/2023
