November 2019 In The Know


Required training for VIP Prime Network due Dec. 15

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 2019 EmblemHealth SNP MOC provider training by Dec. 15. 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. Providers who do not complete the training may be removed from the EmblemHealth Provider Directory.

Medicare Advantage Annual Open Enrollment Ends Dec. 7

Medicare members must select their medical and prescription drug coverage for 2020 during open enrollment. Please remind your Medicare patients now is the time to make coverage elections. Please review health coverage needs with your Medicare Advantage patients so they can choose the right plan for them. has both detailed plan descriptions and simple guidance to help your patients choose the right plan at a price they can afford.

We welcome Medicare providers in our expanded service area: Albany, Broome, Columbia, Delaware, Greene, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, and Washington Counties. If asked, you may let your patients know you will be an in-network provider for the VIP Prime Network starting Jan. 1. EmblemHealth members will also have access to in-network coverage in Connecticut through ConnectiCare’s Medicare providers.

Medicare members transitioning from Montefiore CMO to EmblemHealth in 2020

On Jan. 1, Montefiore Care Management CMO will no longer be a managing entity for Medicare members. EmblemHealth will now be responsible for claims payment and utilization as well as case and disease management services. Members’ primary care physicians (PCPs) will not change. Providers will need to be registered to use the secure provider portal at to manage referral and preauthorization transactions. Referrals made within the Montefiore system for a member assigned to a Montefiore PCP do not need to be entered into the EmblemHealth website. If you need to learn how to use EmblemHealth’s secure portal, register for a live webinar held the second Wednesday of each month.

Open enrollment for New York State Marketplace Ends Jan. 31, 2020

2020 Open Enrollment started Nov. 1, and renewals began Nov. 16 for individuals and small groups for enrollment in a health plan through the New York State Marketplace.


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.


Remind your patients to get their flu vaccine

The flu vaccine is the best way to prevent this common but serious respiratory infection. Remind your patients that the flu virus changes each year and a new vaccine is needed, even if they received a flu vaccine last year. Speak with your patients about vaccine safety and minor side-effects such as injection site tenderness which may occur. If the vaccine is the only reason for the office visit, then no copayment is collected as this is a preventive care service. If your office does not carry the vaccine, direct your patients to their local pharmacy.

Change in referral requirements for initial PT visit and routine diagnostic x-rays

Effective immediately:
  • A referral is no long required for the initial evaluation visit for physical and occupational services.
  • A referral is no longer required for routine diagnostic x-rays and other radiology services that do not require preauthorization. Preauthorization is required for services managed by eviCore.

Changes to utilization management and preauthorization requirements start Jan. 1

EmblemHealth is introducing new preauthorization (PA) requirements Jan. 1, 2020. We are reducing the number of codes that require PA by half and are adopting a strategy that limits your need to seek preauthorization based on the type of plan the member has (Commercial, Medicaid, and Medicare). The changes will apply to most members Jan. 1. For full details, see the UM and Medical Management page of Claims Corner on our provider website. Click here for additional information.

New information on electronic test requests, accessing laboratory reports, and a revised Wadsworth Center infectious diseases requisition form

The Wadsworth Center is introducing electronic submission protocols to increase efficiency, turnaround time, tracking accuracy, and availability of information. For full information see Requesting tests electronically through the Health Commerce System (HCS) is preferred and recommended. If an electronic test request is not possible, submitters are asked to use Infectious Diseases Requisition form DOH-4463 (6/19), which is available for download at For questions or further information, please contact the Wadsworth Center at or 518-474-4177.

Medical policy updates

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

Medical technologies database

A comprehensive listing of medical technologies reviewed by the Medical Policy Committee for coverage consideration is available for download on our provider website in Clinical Corner.


A comprehensive listing of medical technologies reviewed by the Medical Policy Committee for coverage consideration is available for download on our provider website in Clinical Corner.


Join us Dec. 11 for our monthly webinar

Practitioners and office staff are welcome to join our monthly webinar that 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 session to be held Dec. 11 from 10 to 11 a.m. or 2 to 3 p.m. Space is limited. Register today


New Bridge Network now available

The Bridge Network is a new name that combines the existing EmblemHealth or ConnectiCare networks in which you participate. Members who have the Bridge Network on their member ID cards belong to self-funded employer groups for which EmblemHealth and ConnectiCare are providing administrative services and access to our commercial networks. If you are interested in receiving payment via electronic funds transfer (EFT) or paper checks rather than virtual credit cards, you will need to enroll with ECHO Health, Inc. (ECHO) even if you are currently enrolled in EFT for EmblemHealth payments. See our website for instructions.

New Medicaid benefits now available

Children’s Home and Community Based Services (HCBS) offers personal, flexible support services for children, youth, and families at home and in the community. Members under the age of 21 can get these services from EmblemHealth. An EmblemHealth care manager will help members get the services that are right for them.

Follow Access and Availability Standards

It’s important for our members to get the right care at the right time. See our Appointment Availability Standards During Office Hours & After Office Hours Access Standards brochure available on the Provider Toolkit in the Provider Resources section of our provider website. Refer to it often and share it with appointment schedulers.
Provider Update
eNews Policy Update