July 2020 In The Know


More Payment Options Coming Soon

Beginning Aug. 19, EmblemHealth will offer our providers expanded payment and remittance delivery options, including an ECHO Health virtual payment card, when we roll out a new Claims Payment and Remittances (CPR) service powered by ECHO Health, Inc. (ECHO®), a service of PNC Bank.

Our EmblemHealth providers will move to the ECHO system on Sept. 2.

Once we move to the PNC ECHO CPR system, paper checks will be replaced with vCards. Providers whose claims were previously paid with a paper check will be paid with a virtual card known as vCard. You will see both ECHO Health and QuicRemit on the card. If you are currently being paid by paper check and want to move to EFT/ERA instead of being paid by vCard, you must register for PNC Remittance Advantage before Aug. 5 in order to be ready for the transition. Or, you can wait until your first virtual credit card payment to make the switch.

For more information, see the copy of the letter and transition schedule being sent to our providers by ECHO.

Electronic Preauthorization Through ESI for Pharmacy Starts Aug. 3

Beginning Aug. 3, Express Scripts will perform utilization management services for most drugs for all Commercial and Health Exchange EmblemHealth plan members. The services include preauthorizations, quantity limits, and step therapy. This new process is fast, secure, and simple, and reduces the administrative burden that comes with getting your patients the medications they need. Click here for more information and the letter mailed earlier this month.

Special Enrollment Period Extended to Aug. 15

The special enrollment period for uninsured New Yorkers has been extended through Aug. 15. Because of the continuing COVID-19 emergency, New Yorkers can apply for coverage during this time through the New York State of Health, The Official Health Plan Marketplace, or directly through EmblemHealth. This is important as unemployment continues to grow in New York, and we are all committed to helping people get the insurance coverage they deserve.

Improved Provider Customer Service — Have NPI Ready

Starting in late August, you will need to have your NPI (National Provider Identifier) when you call our Provider Customer Service team. This will help speed up our responses to your calls. Please continue to have the name of the patient and his/her member ID number handy, too.

Reminder: Prepayment Forensic Reviews and Post-Pay DRG Audits Resumed June 30

EmblemHealth resumed its high-dollar, prepayment forensic reviews as well as the post-payment diagnosis-related group (DRG) and implant audits on June 30. These audits apply to paid facility claims. Our partner, Optum/Equian, will retrospectively review the high-dollar claims paid during the coronavirus (COVID-19) crisis period that had qualified for prepayment reviews that were suspended due to the Department of Financial Services Circular Letter 8.

Reminder: NYC EmblemHealth PPO Members — New IDs and New ID Cards

In June, NYC EmblemHealth PPO members and their dependents were issued new member IDs using the new K-ID format and new member ID cards. Empire BlueCross BlueShield (BCBS) issued new IDs and ID cards using the same first 9 digits as EmblemHealth’s K-ID. Dependents of NYC Medicare-eligible members received their own unique member IDs.

IMPORTANT NOTE: We are receiving calls about new ID cards for City of New York employees and non-Medicare retirees with EmblemHealth PPO benefits managed by Empire BlueCross BlueShield. These plan benefits include inpatient care, skilled nursing and rehabilitation, as well as all outpatient and DME services. When calling Empire BlueCross BlueShield's IVR to retrieve information about these members, or entering the digits into an Empire BCBS system, please use only the first 9 alphanumeric digits of the member ID. Do not use the last 2 digits of the member ID as these will NOT be recognized by their system.

EmblemHealth Providers May See Bridge Program Members

Recently we have heard from Bridge Program members that they were turned away by EmblemHealth providers who did not know they were considered in-network for these members. 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. Tthe Bridge Network also includes providers who are contracted with these other networks. Click here for payment protocols and click here for details on how to manage Bridge members.


Member Cost Share — Places of Service 22 and 19

Please be sure to tell your Medicare members they may be responsible to pay for applicable facility charges when they receive services in outpatient hospital settings, both on and off the main hospital campus, rather than in a physician office or ambulatory care facility.

Complete 2020 Annual SNP MOC Training by Sept. 30

CMS requires all Medicare providers to complete annual Special Needs Plan (SNP) Model of Care (MOC) training. Providers in the VIP Prime Network must complete the 2020 EmblemHealth SNP MOC provider training by Sept. 30. Look for notices to arrive by email, fax, and postal mail (if we cannot reach your office electronically) with the user ID and PIN number for this online training. Or, to download the training and submit an attestation form, go here.

CMS Advisory: Medicare Ambulance Benefit

For Medicare ambulance transportation to qualify as a Medicare-covered service, actual transport of a Medicare beneficiary must occur. If more than one ambulance arrives at the pickup point, only the one the member uses may bill for the service. Claims submitted by the other ambulance company may be considered by CMS to be fraud, waste, or abuse.


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

EmblemHealth is committed to increasing the quality and efficiency of pediatric screenings for children within their first 1,000 days of life – between the ages of 0 and 3. As part of this quality initiative with the New York State Department of Health, you may receive a copy of our comprehensive early screening pocket reference guide, “The First 1,000 Days“. It has information on early identification, prevention, diagnosis, treatment, intervention, and follow-up care for lead exposure, newborn hearing loss, and developmental disorders.

Medicaid: New York State Medicaid Update

The Office of Health Insurance Programs of the New York State Department of Health has posted its June 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.


Updated Clinical Practice Guidelines (CPGs)

The following clinical practice guidelines have been updated and are available on our website.

Medical Policy Updates

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


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

Biosimilar Strategy Launched July 1

Starting  July 1, providers are asked to use our preferred products for all lines of business for bevacizumab, trastuzumab, and rituximab. This does not apply to EmblemHealth City of New York members. Learn More.


Join us Aug. 12 for our monthly webinar

The next session of our monthly webinar series will be held on Wednesday, Aug. 12 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.


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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