January 2020 In The Know


2019 annual provider notification materials available

Each year, EmblemHealth creates a comprehensive summary of updated educational and informational materials sent to providers in the previous 12 months. This digest also includes announcements, new requirements, and plan changes for the coming year. We are proud to share with you this year’s edition and encourage you to review and share this with your clinicians and staff. See our 2020 suite of networks and benefit plans, access to care standards, quick guides, and more on our website.

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 website under your applicable EmblemHealth user IDs.

New, simpler preauthorization rules went live Jan 1.

 See EmblemHealth Reduces Preauthorization Requirements for full information. Here are some of the highlights:

Commercial and Medicaid: EmblemHealth’s new preauthorization requirements went into effect Jan. 1. Based on data gathered, we found our pediatric providers doing such a good job of managing our Medicaid and Commercial children that we removed the need to preauthorize the 99 site-of-service codes introduced in Sept. 2019.

Medicare: In addition to new preauthorization rules effective Jan. 1, we will also introduce site-of-service requirements for our Medicare members starting Feb. 1.

EmblemHealth and Bridge Network: Please call 866-447-9717 to request preauthorization for EmblemHealth PPO members whose member ID starts with the letter “K.” The “K” indicates these members have migrated to our new systems. EmblemHealth-only providers must call 866-833-2729 or fax 866-215-2928 for Bridge Network members.

ASO Bridge members may access EmblemHealth providers

EmblemHealth’s new ASO Bridge offering is growing. Bridge gives members access to a combination of our existing EmblemHealth Prime Network, EmblemHealth National Network, ConnectiCare, Inc. (CCI) Choice Network, as well as QualCare’s and FirstHealth’s Networks. The Bridge Network also includes providers who are contracted with these other networks. If you are an EmblemHealth provider, please do not turn away members assigned to the Bridge Network. Click here (PDF) for payment protocols specific to these members that was mailed to providers in the fall and click here for details on how to manage Bridge members.

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

Jan. 31 is the last day individuals and small groups may enroll in a health plan through the New York State of Health Marketplace.

Medicare Advantage in 2020

We have the following items on our website to help you manage your Medicare Advantage members in 2020:

Medicare Outpatient Observation Notice (MOON)

 All hospitals and critical access hospitals are required by the Centers for Medicare & Medicaid Services (CMS) to provide Medicare beneficiaries, including Medicare Advantage enrollees, with the OMB-approved Medicare Outpatient Observation Notice (MOON). The MOON and instructions for completing it are available on the CMS website.

Health Survey for Medicare and Special Needs Plan members

Please encourage your Medicare and Special Needs Plan members to log in to emblemhealth.com/members and take a Health Risk Assessment (HRA) survey. This will help our care management team direct them to appropriate care and support services. Members may also take this survey by phone at 888-246-2934, 24 hours a day, seven days a week.

Member Rewards Program for Medicare and Special Needs Plan members

Beginning in 2020, Medicare members, including Special Needs Plan members enrolled in EmblemHealth, are eligible to participate in the EmblemHealth Member Rewards Program. This program rewards members for taking good care of their health. Please encourage your Medicare members to log in to emblemhealth.com/members and select “Wellness Rewards” or call 877-344-7364 (TTY: 711), available seven days a week from 8 a.m. to 8 p.m., to learn more. Members can get up to $75 in gift cards per calendar year for receiving select health services. All rewards are triggered by and processed along with the clinician’s claim, so please make sure to submit claims as soon as a service is rendered.

Medicare Beneficiary Identifiers (MBIs)

The Center for Medicare & Medicaid Services (CMS) is sending new Medicare cards to beneficiaries as part of an effort to comply with a law that requires them to remove Social Security numbers (SSNs) from all Medicare cards.


The new cards are for original Medicare and do not apply to Medicare Advantage plans, such as the ones EmblemHealth/ConnectiCare offer. EmblemHealth/ConnectiCare Medicare Advantage ID cards do not use or include SSNs and are not impacted by this change. Please continue to use our identification numbers located on the applicable member ID card for claims and other transactions.

CMS encourages providers to use these new Medicare Beneficiary Identifiers (MBIs). MBIs should be treated like personal health information. To find out what the new cards mean for providers, check out this resource from CMS.

Medicaid: New York State Medicaid Update

The Office of Health Insurance Programs of the New York State Department of Health has posted its October and November 2019 Medicaid Updates.


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.



Fewer plans require referrals

In addition, referral requirements have been removed from more plans in 2020. Click here to see which ones they are and share with your appointment schedulers.

Care options for members when you are not available

Tell your patients about their treatment options. Make sure your members know how to access care when you’re not available. This flyer can help your patients choose the most appropriate site of care.

Remind your patients to get their flu vaccine

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’s safety and minor effects that may occur, such as injection site tenderness. Please remember that 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 in the Clinical Corner section of our provider website.

Medical Technologies Database

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


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

Accredo’s Convenient Care Program

EmblemHealth is partnering with Accredo Specialty Pharmacy to provide members with home infusion treatments through Accredo’s Convenient Care Program. Effective March 1, 2020, the specialty drugs on the list here will no longer be covered in an outpatient setting. Members using an outpatient setting for their treatments will be responsible for the full cost of their drugs and treatment.

To facilitate the transition to this new program, an Accredo pharmacist will reach out to prescribers for new prescription(s). Once the prescription is in place, an Accredo representative will call the member to schedule the delivery of the medicine(s) and/or treatment(s). Members may request a one-time-only refill of their specialty medicine(s) at their current provider after March 1, 2020, if needed.

If you have questions, please call us at 877-793-6253 (TTY: 711), Monday to Friday from 8 a.m. to 6 p.m., and Saturday and Sunday from 10 a.m. to 1 p.m.

You can also call Accredo at 844-581-4862 (TTY: 711). Their hours of operation are Monday to Friday, 8 a.m. to 5 p.m.


Join us Feb. 12 for our monthly webinar

Practitioners and office staff are welcome to join the next session of our monthly webinar, taking place on Wednesday, Feb. 12 from 10 to 11 a.m., or from 2 to 3 p.m. This webinar 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.

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 as outlined in this video and in our Toolkit.

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.

Use network labs – Quest Diagnostics and AmeriPath

Quest Diagnostics and its affiliate, AmeriPath, are our preferred lab s. When an out-of-network lab is used, the data 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 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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