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New York City Employees PPO Plan
Provider Questions

Brooklyn bridge and downtown New York City skyline

Log in to the single, secure portal and learn more about the NYCE PPO plan.

NYCE PPO portal.

A New Plan for City Employees

Effective Jan. 1, 2026 New York City employees, pre-Medicare eligible retirees, and their dependents are now offered the New York City Employees PPO plan (NYCE PPO), a health benefit plan delivered through a partnership between EmblemHealth and UnitedHealthcare.

What’s changing?

  • The member ID card: NYCE PPO members now have one card for both facility care and professional care.
  • Who’s in-network: NYCE PPO is a partnership between EmblemHealth and UnitedHealthcare. The plan uses the EmblemHealth Bridge Program for all facilities and providers in the 13 counties in lower New York state and the UnitedHealthcare national Choice Plus network outside these counties (in the remaining New York state counties and nationwide).
  • The portal: EmblemHealth and UnitedHealthcare providers have a single, secure portal powered by UMR (the third-party administrator that’s part of the same family of companies as UnitedHealthcare).

We have created this list of Frequently Asked Questions (FAQs) to help answer some of the most pressing queries you may have about this plan.

General FAQs

What is NYCE PPO?

NYCE PPO is the name of the new plan offering for New York City employees, pre-Medicare eligible retirees, and their dependents. This plan, effective Jan. 1, 2026, is offered through a partnership between EmblemHealth and UnitedHealthcare.

Under this new plan, current New York City employees, pre-Medicare eligible retirees, and their dependents have access to care through EmblemHealth facilities and providers in 13 counties in lower New York state (see map below). Outside this region, New York City employees, pre-Medicare eligible retirees, and their dependents have access to care through the UnitedHealthcare national Choice Plus network.

EmblemHealth and UnitedHealthcare providers have a single, secure portal powered by UMR (the third-party administrator that’s part of the same family of companies as UnitedHealthcare) to manage their NYCE PPO business.

What is changing for current New York City employees, pre-Medicare eligible retirees, and dependents in the EmblemHealth and GHI CBP/Anthem BlueCross and BlueShield plan (formerly Empire BlueCross BlueShield)?

Under this new plan, New York City employees, pre-Medicare eligible retirees, and their dependents have only one member ID card, easing their experience when setting appointments and receiving care. For providers familiar with the previous plan, New York City employees, pre-Medicare eligible retirees, and their dependents were required to carry two cards: one for facility care, the other for professional care. Now each member has a new member ID card, co-branded with the EmblemHealth and UnitedHealthcare logos, for all their health care needs. GHI CBP/Anthem BlueCross and BlueShield plan member ID cards were valid until Dec. 31, 2025. As of Jan. 1, 2026, members should use the new NYCE PPO member ID. Sample ID card pictured below.

New York City Employees PPO blurred sample ID card.

New York City Employees PPO blurred sample ID card.

What is happening to the PPO plan operated by EmblemHealth GHI CBP/Anthem BlueCross and BlueShield?

Active members of this plan and their eligible dependents were automatically enrolled in NYCE PPO. NYCE PPO replaced the EmblemHealth GHI CBP/Anthem BlueCross and BlueShield plan as of Jan. 1, 2026. There is no gap in coverage.

Is there a specific network arrangement for NYCE PPO?

Yes, members in the following 13 counties in downstate New York can access professional and facility services through providers contracted in networks that are part of the EmblemHealth Bridge Program*:

  • Bronx.
  • Dutchess.
  • Kings.
  • Nassau.
  • New York.
  • Orange.
  • Putnam.
  • Queens.
  • Richmond.
  • Rockland.
  • Suffolk.
  • Ulster.
  • Westchester.

*Bridge Program providers outside of this territory are not in-network for NYCE PPO members, even though they are in-network for other EmblemHealth Bridge Program members. Participation for NYCE PPO outside these counties is solely through UnitedHealthcare-contracted providers.

What is the EmblemHealth Bridge Program?

The EmblemHealth Bridge Program gives our members access to care through a combination of our existing networks’ affiliated companies and partners. For NYCE PPO there is one important change: Bridge Program providers outside the 13 lower New York state counties are not in-network for this new plan even though they are in-network for other EmblemHealth Bridge Program members. Participation for NYCE PPO outside the 13 counties is solely through UnitedHealthcare-contracted providers.

For plans other than NYCE PPO, please reference the Bridge Program web page.

Is a provider considered participating with NYCE PPO if they are currently contracted with EmblemHealth or UnitedHealthcare?

It depends on a provider’s contract and the location of the site of service. A provider is considered participating with NYCE PPO if they are contracted with the EmblemHealth Bridge Program in the downstate 13 counties or the UnitedHealthcare national Choice Plus network outside the 13 counties (in New York and nationwide).

I have office locations in both the 13 downstate counties covered by EmblemHealth and in counties covered by UnitedHealthcare. How am I paid for services to members of this plan?

For providers with office locations that span both geographies, the location where the service is provided determines which company rates — EmblemHealth’s or UnitedHealthcare’s — are applied.

What if I am only contracted with EmblemHealth in the upstate counties (outside of the 13 downstate counties) and not contracted with UnitedHealthcare in the upstate counties?

If you are contracted with EmblemHealth but not UnitedHealthcare and your service location is outside of 13 downstate New York counties (see map below), you are considered out-of-network for this plan. If you are not contracted with EmblemHealth in the 13 downstate counties but have a contract with UnitedHealthcare, you are considered out-of-network for this plan. In both cases, you can still provide care to NYCE PPO members, but it will be paid at the out-of-network rate according to the member’s benefit plan. You can also join EmblemHealth’s or UnitedHealthcare’s networks.

Does a provider have to be contracted with EmblemHealth or UnitedHealthcare to provide care to NYCE PPO members?

No, this is plan allows members to get care from both participating and nonparticipating providers.

What is the process if I want to become a participating provider with EmblemHealth to provide care to NYCE PPO members?

If you wish to provide in-network service to NYCE PPO plan members and your practice is in the 13 downstate New York counties (see map below), please visit the EmblemHealth Join Our Network page for guidance. You can also join UnitedHealthcare’s national Choice Plus network.

How are contracted providers reimbursed?

Reimbursement is based on your contracted rate and EmblemHealth’s product grid. For details, contracted providers should review their contract:

  • Facilities and providers, excluding behavioral health specialists, in the 13 downstate counties are reimbursed per their contract with EmblemHealth for the Bridge Program.
  • Facilities and providers outside the 13 downstate counties are reimbursed per their contract with UnitedHealthcare.
  • Behavioral health specialists in all areas covered by this plan are reimbursed per their contract with UnitedHealthcare.

Pharmacy services for prescription drugs are provided through Prime Therapeutics, EmblemHealth’s pharmacy vendor as of Jan. 1, 2026.

How are noncontracted providers reimbursed?

Noncontracted providers are out-of-network providers and are reimbursed using the out-of-network rates under EmblemHealth or UnitedHealthcare, depending on where the service was rendered.

Are NYCE PPO members required to select a primary care provider (PCP)?

No.

Do NYCE PPO members need a referral to see a specialist?

No.

How can member eligibility and benefits be verified?

Member eligibility and benefits can be verified online using the provider portal:

  • Eligibility, benefits, claims, commonly used forms, and remit information are available through the secure provider portal, powered by UMR.

Phone: Call the Provider Service number on the back of the member’s ID card. 

Will I still have access to the EmblemHealth provider portal for care provided to New York City members prior to Jan. 1, 2026?

Yes, you can access the EmblemHealth provider portal for dates of service prior to Jan. 1, 2026, or to manage patients with other EmblemHealth plans.

Is prior authorization required?

It depends on the service. We require preauthorization for select in-network health care services. The same preauthorization rules apply to non-contracted health care professionals.

How do I request a prior authorization?

You can use one of the following methods to request prior authorization:

Authorization Guide for information and instruction.

  • Phone: Call Customer Services at 844-849-5750 (on the back of the member’s ID card) and follow the prompts.

What if my patient started care (inpatient or outpatient) in 2025 and is still in treatment after Jan. 1, 2026?

The prior authorization submitted to the EmblemHealth GHI CBP/Anthem BlueCross and BlueShield plan for services starting in 2025 will be honored by the New York City PPO plan after Jan. 1, 2026.

How do I submit authorization requests during the transition?

Prior authorization requests for services beginning Jan. 1, 2026, can be submitted in the

NYCE PPO provider portal or call Provider Services at 844-849-5750. If services started before Jan. 1, 2026, requests should be submitted to the EmblemHealth GHI CBP/Anthem BlueCross and BlueShield plan.

How do NYCE PPO providers request prior authorizations for prescription drugs for the 2026 plan year?

For prescriptions covered under EmblemHealth’s pharmacy benefit on or after Jan. 1, 2026, providers can: 

  • Contact Prime Therapeutics Pharmacy Benefit Management at 866-799-7919. 
  • Request prior authorizations at covermymeds.com. 

Before Jan. 1, 2026, prior authorizations are handled by ExpressScripts®. 

On or after Dec. 22, 2025, for drugs covered under the NYCE PPO medical benefit for the 2026 plan year, providers can: 

  • Contact Prime Therapeutics Medical Pharmacy Solutions at 833-519-4548.
  • Providers in the 13 downstate New York counties can also request prior authorizations online at gatewaypa.com. 

Clarifications and other pharmacy-related requests are managed by Prime Therapeutics. Visit covermymeds.com or call Prime Therapeutics Pharmacy Benefit Management at 866-799-7919.

Does NYCE PPO require advance patient notification for services not covered under this plan?

Providers are encouraged to contact the plan for a formal determination of coverage if the provider thinks a service may not be covered.

How do NYCE PPO providers request prior authorizations for prescription drugs for the 2026 plan year?

For prescriptions covered under EmblemHealth’s pharmacy benefit on or after Jan. 1, 2026, providers can: 

  • Contact Prime Therapeutics Pharmacy Benefit Management at 866-799-7919.

Before Jan. 1, 2026, prior authorizations are handled by ExpressScripts®. 

Can providers collect cost share amounts up front from these plan members?

Yes, providers may request the member’s cost share at the time of service.

Can plan members be balance billed?

Not for covered in-network services. For covered in-network services, NYCE PPO members may only be billed the applicable member cost share as indicated on the provider remittance.

Will there be any additional ways for providers to learn more about this plan?

We will continue to keep our providers informed about NYCE PPO through email, website updates, videos, live/recorded webinars, mailings, in-person presentations, telephone calls, and more. We also have a flyer with some questions providers and their patients may have about NYCE PPO.

Claim Submission FAQs

What is the new claim payer ID?

Beginning Jan. 1, 2026, you’ll submit claims using payer ID 26992.

What is the claims submission process?

For services before Jan. 1, 2026, claims should be submitted to EmblemHealth/Anthem using the existing process:

  • EmblemHealth professional claims should be submitted electronically to EmblemHealth using payer ID 13551 or mailed to:
    EmblemHealth
    P.O. Box 2832
    New York, NY 10116-2832
  • EmblemHealth facility claims should be submitted electronically to EmblemHealth using payer ID 13551 or mailed to:
    EmblemHealth
    P.O. Box 2833
    New York, NY 10116-2833
  • For Anthem facility submissions, please follow the existing process to submit to Anthem.

For services on or after Jan. 1, 2026, claims are submitted to UMR using payer ID 26992 to the following:

  • EDI number 26992
  • NYCE PPO Plan, P.O. Box 21534, Eagan MN 55121
  • Issuer (80840) 911-39026-02

Who do we contact on or after Jan. 1, 2026, for information about claims submitted to the previous plan that have a date of service prior to Jan. 1, 2026?

For all services before Jan. 1, 2026, please contact EmblemHealth by either signing in to your provider portal and sending us a message or calling Provider Services at 866-447-9717. Our provider manual has more information on claims contacts.

What is the process for submitting an appeal on a claim or a claim for reconsideration?

For dates of service before Jan. 1, 2026, submit appeals or requests for reconsideration to the following:

  • Professional claims handled by EmblemHealth, Provider Grievances, and Clinical Appeals can be filed as follows:
    • EmblemHealth provider portal
    • By mail: P.O. Box 2844, New York, NY 10116-2844
    • By fax: 212-510-5320
  • For facility submissions, please follow the current process to submit to Anthem.

For dates of service on or after Jan. 1, 2026, submit appeals or requests for reconsideration to UMR:

General claims:
NYCE PPO Plan
P.O. Box 21534
Eagan, MN 55121		 Appeals:
CNY Post Service Appeals
P.O. Box 211381
Eagan, MN 55121		 MAPFRE:
MAPFRE Life
P.O. Box 70297
San Juan, P.R. 00936-8297

If you have questions not answered here, please contact your relationship manager or call us at 844-849-5750.

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