As of Jan. 1, 2024, members in all HMO products (except Medicaid) will no longer be automatically assigned to your practice, or remain attributed to you, unless they choose you as their primary care provider (PCP) or if a claim shows they have been cared for by a PCP in your practice.
The previous policy, starting Jan. 1, 2023, allowed PCPs to keep commercial and Medicare auto-assigned members whether or not the provider saw these members. Medicaid members were auto-assigned to select provider groups. Beginning in 2024, Medicaid members will now be automatically assigned to provider groups based on demographic and location needs to be consistent with state policy.
Attribution for all HMO lines of business will now be as follows:
- For all lines of business, members who choose a provider in your practice as their PCP will be attributed to your provider panel as of the date they chose that provider as their PCP. These members will remain paneled to your practice regardless of the utilization reporting process outlined below since they actively chose a provider in your practice as their PCP of record.
- For all lines of business, for those members who have obtained services from your practice, EmblemHealth will run a monthly claims utilization report for members in all HMO lines of business with no assigned PCP to check for preventive visits, other evaluation and management (E&M) PCP visits, lab services referred by PCP, and prescriptions written by a PCP. If they have utilization with any of your PCPs, EmblemHealth will assign that member to your group as of the first of the month.
- A quarterly claims utilization report will be run by EmblemHealth to check utilization for all HMO members currently assigned to PCPs for all lines of business.
- If a member continues to use PCPs in your practice, then they will remain attributed to your practice.
- If a member previously cared for by a PCP in your practice receives care from a different practice, they will be assigned to that practice starting on the date of the first PCP visit with that other practice.
- If a member does not have utilization with any PCP in your practice, they will no longer be attributed to your practice at the end of the quarter.
Capitation payments will be impacted by these changes and recoupments may be initiated, as applicable.
By implementing this new PCP assignment process, we aim to support proactive patient engagement and foster good provider-patient relationships.
Assisting members with their PCP selection in this manner helps to facilitate any possible clinical care coordination, should it be necessary, and helps empower the member to achieve better overall wellness. We believe this change will help connect our members to the quality health care you provide and enable insights that accurately reflect the members whose care you manage.
JP 64661 02/2024
