New Policies
We are introducing three new reimbursement policies that will apply to both EmblemHealth and ConnectiCare.
HCPCS and CPT Coding Requirements for Outpatient Claims
We have a new formal cobranded HCPCS and CPT Coding Requirements for Outpatient Claims Reimbursement Policy. There are no changes to the policy criteria, only reformatted/transferred content to new template.
Part D Vaccine Billing Guidelines (Medicare) Reimbursement Policy
Starting May 16, 2023, the Part D Vaccine Billing Guidelines (Medicare) Reimbursement Policy that has been in effective for ConnectiCare will also apply to EmblemHealth. Consistent with guidance from the Centers for Medicare & Medicaid Services (CMS), EmblemHealth and ConnectiCare will not reimburse claims for Part D vaccines administered in the physician’s office and submitted under the Part B medical benefit.
Split/Fragmented Billing Services Policy
Starting June 4, 2023, the new Split/Fragmented Billing Services Reimbursement Policy for EmblemHealth and ConnectiCare will require all services rendered by the same provider on the same date of service to be filed on a single claim. Billing them on different claims prevents the application of claim edits and adjudication logic. This may result in an overpayment or underpayment and the member’s cost share incorrectly applied.
Claims found to be split billed will be subject to pre-pay/post-pay audits, denials, and recoveries.
Revised Policies
The following two reimbursement policies have been updated. See revision histories for applicable changes:
JP 61384 02/2023
