June 2019 In The Know


Pre-authorization list changes slated for August 1 for HIP Commercial & Medicaid members

Beginning August 1, 2019, for HIP’s Commercial and Medicaid lines of business, we will supplement our current utilization management pre-authorization list with 99 codes (27 current and 72 new) that have site-of-service rules. All other codes remain unchanged, and will continue to apply to all members. The site-of-service rules identify procedures that do not require a pre-authorization if performed in certain office settings (POS 11) or in an ambulatory surgery center (POS 24). To help you find our pre-authorization rules, we added a new section to Clinical Corner.

The same rules apply to all managing entities (HIP, Montefiore CMO, and HealthCare Partners) and delegates who conduct utilization management on our behalf.

Reminder: Medicaid Children’s Behavioral Health Services start July 1

Starting July 1, 2019, the EmblemHealth Enhanced Care plan covers more behavioral health services (community-based recovery-oriented services and supports) for children and youth. See our Appointment Availability Standards which have been updated to reflect these new services.

New contact information for LTSS for Medicaid and GHI PPO members

We have a new fax number and email address for you to request Long-Term Support Service (LTSS) for Medicaid members needing Personal Care Services, Consumer Directed Personal Assistance Services, Private Duty Nursing, Adult Day Health Care, and Personal Emergency Response Services. This also applies to GHI PPO members needing Private Duty Nursing. Please email: longtermsupportservices@emblemhealth.com or fax requests to: 212-510-5248. You may also use the email to send us your LTSS questions.

EmblemHealth opens Neighborhood Care location in Staten Island

EmblemHealth has opened a new Neighborhood Care center at 2655 Richmond Avenue in Staten Island. Learn more.

Review your directory information today

See video on how to make updates. If you are leaving a service location, please notify us as soon as possible so we can support you and your patients with appropriate transitions of care.

Check PCP Panel Reports and schedule new patient visits

Primary care physicians: Please run PCP Panel Reports at emblemhealth.com/providers to identify new patients needing first visit outreach calls. Please encourage new Medicare and Dual Eligible Special Needs Plan (SNP) members to complete and submit their Health Risk Assessments.


Medical Policy Updates

This month’s update includes one new policy: Telehealth Commercial/Medicaid, and revisions to the following medical policies: Transcatheter Aortic Valve Replacement, Radiofrequency Ablation of Tumors, Insulin Delivery Devices and Continuous Glucose Monitoring Systems.

Medical Technologies Database Updated May 2019

To see the latest updates, click here.


The Claims Corner section of our provider website is a rich resource of information that helps your practice navigate EmblemHealth claims and billing processes. See new Gastroenterology Policy.


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


Required SNP MOC training coming soon

The annual training for Special Needs Plan (SNP) Model of Care (MOC) will launch soon. The training is required for providers who participate in the VIP Prime Network. Look for our notice to arrive via email, fax, and postal mail. The communication will include the user ID and PIN number needed for this required training.

New to EmblemHealth? Join us on July 10 for our monthly webinar for practitioners and office staff

This webinar 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 webinar on July 10, 2019 10 to 11 a.m. or 2 to 3 p.m. Space is limited, Register today
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