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The City of New York PPO Strong Plan
FAQs for Providers

Effective <<Go-Live Date>>, City of New York employees, non-Medicare retirees, and their dependents will be offered The City of New York PPO Strong Plan, a health benefit plan delivered through a partnership between EmblemHealth and United HealthCare.

In the months leading up to the launch, provider education materials and training opportunities specific to The City of New York PPO Strong Plan will be made available to all providers in both EmblemHealth’s and United HealthCare’s networks.

For now, we have created this list of Frequently Asked Questions to help answer some of the most pressing concerns providers may have about this plan. If you have questions not answered here but you wish to see answered, please email cnyppostrongprovidersupport@umr.com.

Frequently Asked Questions

What is The City of New York PPO Strong Plan?

The City of New York PPO Strong Plan is the Preferred Provider Organization (PPO) offering for City of New York employees and their dependents. Under this new plan, current City of New York employees and their dependents will have access to care through EmblemHealth facilities and providers in 13 counties in lower New York State (a list of counties appears below). Outside of this region, City of New York employees and their dependents will have access to the UnitedHealthcare Choice Plus network across the nation.

This plan, effective <<Go-Live Date>>, is offered through a partnership between EmblemHealth and UnitedHealthcare (United). EmblemHealth and United providers will access a single, secure portal powered by UMR to manage their PPO Strong business.

What is changing for current City of New York employees and dependents from the PPO plan operated by EmblemHealth and Anthem Blue Cross Blue Shield (formerly Empire Blue Cross Blue Shield)?

Under this new plan, New York City employees, non-Medicare retirees, and their dependents will have only one member ID card, easing their experience when setting appointments and receiving care. For providers familiar with the previous plan, City of New York employees, non-Medicare retirees, and their dependents were required to carry two cards—one for facility care, the other for professional care. Now each member will receive a new member ID card, co-branded with the EmblemHealth and UnitedHealthcare logos, for all their health care needs. The following is an example of what it will look like:

<Insert photo>

 

Sample member ID card for illustration only; actual information varies depending on payer, plan, and other requirements. Current member ID cards will be valid until <<GLD-1>>. Beginning on <<Go-Live Date>>, members should use the new City of New York PPO Strong plan member ID.

 

EmblemHealth insurance plans are underwritten by EmblemHealth Plan, Inc., EmblemHealth Insurance Company, and Health Insurance Plan of Greater New York (HIP). EmblemHealth Services Company, LLC provides administrative services to EmblemHealth companies. The EmblemHealth companies are separate companies from UnitedHealthcare.

Is there a specific network arrangement for The CNY PPO Strong Plan?

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

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

* Bridge Program providers outside of this territory will not be in-network for The CNY PPO Strong Plan even though they are in-network for other EmblemHealth Bridge Program members. Participation for PPO Strong outside of these counties is solely through United-contracted providers. (Image below for placement only)

What is the EmblemHealth Bridge Program?

The EmblemHealth Bridge Program gives our members access to a combination of our existing networks through our affiliated companies and partners. For The City of NY PPO Strong Plan there is one important change: Bridge Program providers outside of the 13 lower New York State counties serviced by EmblemHealth under The City of NY PPO Strong Plan will not be in-network for this new City plan even though they are in-network for other EmblemHealth Bridge Program members. Participation for The City of NY PPO Strong Plan outside of the 13 counties is solely through United-contracted providers.

Is a provider considered participating with The CNY PPO Strong Plan if the provider is currently contracted with EmblemHealth or United?

Yes, a provider is considered participating with The City of NY PPO Strong Plan if the provider is contracted with EmblemHealth Bridge program in the downstate 13 counties or the United Choice Plus network outside of 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 will determine which company rates—EmblemHealth’s or United’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 United in the upstate counties.

If you are contracted with EmblemHealth but not United and your service location is outside of the 13 downstate New York counties listed above, you are considered out of network for this plan. Conversely, if a provider is not contracted with EmblemHealth in the 13 downstate counties but does have a contract with United, the provider is considered out of network for this plan.  In both cases, you can still provide care to City PPO Strong members, but it will be paid at the out-of-network rate according to the member’s benefit plan.

Does a provider have to be contracted with EmblemHealth to provide care to The City of NY PPO Strong Plan members?

No, The City of NY PPO Strong Plan is a Preferred Provider Organization (PPO) plan that 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 The City of NY PPO Strong Plan members?

If you wish to provide in-network service to City of New York PPO Strong members and your practice is in the 13 downstate New York counties listed above, please visit the EmblemHealth Join Our Network page for guidance.

How are contracted providers reimbursed?

Reimbursement is based on your contracted rate. For details, contracted providers should review their contract:

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

How are noncontracted providers reimbursed?

Noncontracted providers are out of network providers and will be reimbursed using the out of network rates under EmblemHealth.

Claim Submissions:

What is the new claim payer ID?

Beginning <<Go-Live Date>>, you’ll submit claims using payer ID 39026.

What is the claims submission process?

For services before <<Go-Live Date>>, claims should be submitted to EmblemHealth/Anthem using the existing process:

  • EmblemHealth professional claims should be submitted electronically to EH using payer ID 13551 or mailed to:

EmblemHealth
PO Box 2832
New York, NY 10116-2832

  • EmblemHealth facility claims should be submitted electronically to EH using payer ID 13551 or mailed to:

EmblemHealth
PO Box 2833
New York, NY 10116-2833

  • For Anthem facility submissions, please follow the existing process to submit to Anthem.

For services after <<Go-Live Date>>, claims will be submitted to UMR using payer ID 39026. (Claim address TBD as custom PO box will be created <Need electronic claim process>

 

Who do we contact after <<Go-Live Date>> for information about claims submitted to the previous plan that have a date of service prior to <<Go-Live Date>>?

For all services before <<Go-Live Date>>, please contact EmblemHealth by either logging into your provider portal account and sending us a message or calling Provider Services at 866-447-9717. For more information, please visit emblemhealth.com/providers/manual/directory/claims-contacts

 

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

For dates of service before <<Go-Live Date>>, you will 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: PO Box 2844, New York, NY 10116-2844
    • Fax: 1-212-510-5320
  • For facility submissions, please follow the current process to submit to Anthem.

For dates of service after <<Go-Live Date>>, you will submit appeals or requests for reconsideration to UMR: <need process>

Are PPO Strong Plan members required to select a primary care physician (PCP)?

No

Do PPO Strong Plan 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 all available through the secure provider portal, powered by UMR. If you do not have a provider portal account, we encourage you to register at your earliest convenience.
  • Phone: Call the Provider Service number on the back of the member’s ID card.

Do I still have access to the EmblemHealth portal for care provider to City of New York members prior to <<Go-Live Date>>?

Yes. You will still be able to access EmblemHealth provider portal for dates of service prior to <<Go-Live Date>> or to manage patients with other EmblemHealth plans.

Is preauthorization required?

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

How can a provider request preauthorization?

Providers are encouraged to use the provider portal, powered by UMR, to request preauthorization but may request by fax and phone as well:

  • Online: Visit CNYPPOStrong.com to submit a request.
  • Phone: Call the Provider Services number on the back of the member’s ID card and follow the prompts.

Does The CNY PPO Strong Plan 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.

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 in-network services. For in-network services, the City of New York PPO Strong Plan 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 The City of New York PPO Strong Plan through a variety of channels, including email, website updates, videos, live/recorded webinars, mailings, in-person presentations, telephone calls, and more.

If you have questions not answered here but you wish to see answered, please email cnyppostrongprovidersupport@umr.com.

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