Starting Nov. 14, 2024, our current ConnectiCare Observation Stay Reimbursement Policy will be expanded to EmblemHealth except for the City of New York’s plans. Under this new policy, we will no longer reimburse observation hours that are fewer than eight hours or more than 48 hours. These policies follow Centers for Medicare & Medicaid Service guidance.
Observation Stay – Medicare/Medicaid Policy
Observation Stay – Commercial Policy
Ambulatory Surgical Center Groupers
As of July 1, 2024, the ASC Grouper 2024 reimbursement policy for EmblemHealth and ConnectiCare has been updated to include new codes as shown in the revision history. For provider contracts that follow a grouper payment methodology, ambulatory surgical center groupers will be paid according to surgical contracted rates when billed with revenue codes 360 or 490. If surgical services are billed with revenue codes other than 360 or 490 — and the claims contain charges for anesthesia and/or recovery room — claims will be paid according to the surgical contracted rates unless otherwise negotiated.
Updated Reimbursement Policies
The Facility Fees for E&M Services on Outpatient Facility Claims (Commercial, Medicare and Medicaid) reimbursement policy was updated to clarify that EmblemHealth and ConnectiCare follow the Centers for Medicare and Medicaid Services (CMS) guidelines regarding off-campus provider-based department/clinic reporting requirements for CPT Code G0463 (Clinic Visit Services). A link was added to the Modifiers PN & PO for Clinic Visit Services (G0463) (Medicare) Reimbursement Policy which was also updated as shown in the revision history.
ConnectiCare’s Experimental Investigational or Unproved Services Policy has been updated to add and remove codes as shown in the revision history.
JP66620 08/2024