June 2020 In The Know



Inpatient and Outpatient Preauthorization Update

As you know, New York State ordered a stop to elective surgeries and procedures due to the COVID-19 emergency (New York State Executive Order 202.10). We believe it is vital for members to have access to needed care, so we are reaching out to members and providers to help:

  • For inpatient procedures, providers with open authorizations may receive a letter from us asking for them to contact us so we can work with them to extend the expiration date of the authorization, if needed.
  • For outpatient services, EmblemHealth is extending the preauthorization date for affected members until Dec. 31, 2020. In this case, both members and their providers will receive letters with the information about their open authorizations.

For more COVID-19 updates, please visit our dedicated COVID-19 website.

July 1 Reminder: New IDs for EmblemHealth PPO City of NY

City of New York members with EmblemHealth PPO plans will move to our new claims platform on July 1. Members will be issued the same type of member ID numbers (the “K-ID”) as other EmblemHealth PPO members who migrated to the new system. The last two digits will distinguish the subscriber from each dependent, but the first set of digits will no longer be used as an identifier for NYC EmblemHealth PPO members. Click here to see changes that will apply once the new K-ID is in effect.


2020 Annual SNP MOC Training Launching Soon

CMS requires all Medicare providers 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 a notice to arrive via email, fax, and postal mail with the user ID and PIN number needed to access this online training. Providers who prefer to download the training and submit an attestation form confirming completion may do so here.


Medicaid: New York State Medicaid Update

To see the most recent updates from The Office of Health Insurance Programs of the New York State Department of Health, visit their website.


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.

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.
Learn More.

Cytogenetic Studies

EmblemHealth has instituted a payment policy for cytogenetic studies, the microscopic examination of the physical appearance of human chromosomes as defined by CMS.
Learn More.


New Preauthorization Lookup Tool

EmblemHealth has introduced a new and improved Preauthorization Checker for EmblemHealth members. Our new Preauthorization Checker does not require you to log in. You can find it pre-login in Clinical Corner where we house our preauthorization lists. To see it after you’ve logged in to the secure provider portal, select Prior Approval/Pre-Certification and the new tool will now be found in the left hand navigation bar. Information is subject to a member’s benefit plan and eligibility on the date of service.

Updated Clinical Practice Guidelines (CPGs)

The following Clinical practice guidelines have been updated and are available on tour website.

Medical Policy Updates

All Medical Policies are available for download in Clinical Corner on our provider website. See updates to the following:

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.

EmblemHealth Introducing Biosimilar Strategy

Starting July 1, 2020, EmblemHealth has selected preferred products for all lines of business for bevacizumab, trastuzumab, and rituximab. This does not apply to EmblemHealthCity of New York members.
Learn more.


Join us July 8 for our monthly webinar

The next session of our monthly webinar series will be held on Wednesday, July 8 from 10 a.m. to 11 a.m., and again from 2 p.m. 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 into 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.
Provider Update
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