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The EmblemHealth and ConnectiCare  Annual Fee Schedule Update payment integrity policies have been updated. See the revision histories for effective dates and applicable changes.

The following reimbursement policies have been updated. If the policy name does not have a company name shown, the policy applies to both EmblemHealth and ConnectiCare. Refer to the website applicable to the member’s plan (EmblemHealth | ConnectiCare) and see the revision histories for effective dates and applicable changes.  Lab Benefit Management policies have “(LBM)” after the policy name.

• Ambulatory Surgical Groupers Reimbursement Policy.
• Biomarkers for Myocardial Infarction and Chronic Heart Failure (LBM).
• Bundled Services (Commercial and Medicare) Reimbursement Policy.
• Cardiovascular Disease Risk Assessment (LBM).
• Coding Edits Policy. 
• Coding Edits Reimbursement Policy.
• Computer Assisted Surgical Navigation.
• ConnectiCare Preventive Care Services (Commercial and Medicare). 
• Coronavirus Testing in the Outpatient Setting (LBM).
• EmblemHealth Preventive Care Services (Commercial).
• EmblemHealth Preventive Care Services (Medicare). 
• Folate Testing (LBM).
• General Inflammation Testing (LBM).
• Hepatitis Testing (LBM).
• Identification of Microorganisms Using Nucleic Acid Probes (LBM).
• Laboratory/Venipuncture Reimbursement Policy.
• Modifier Reference Reimbursement Policy.
• Pancreatic Enzyme Testing for Acute Pancreatitis (LBM).
• Pathogen Panel Testing (LBM).
• Preventive Care Services (Commercial) Reimbursement Policy.
• Preventive Care Services (Medicare) Reimbursement Policy.
• Robotic Surgery.
• Serum Testing for Evidence of Mild Traumatic Brain Injury (LBM).
• Serum Tumor Markers for Malignancies (LBM).

We’d like to remind and encourage all our providers to sign up for electronic funds transfer (EFT) if you haven’t already done so. 

EmblemHealth has partnered with PNC/ECHO Health Inc. for the past five years to handle our claims payments and remittances (CPR) for our providers. 

This arrangement with PNC/ECHO simplified our claims payment process by using one system for all payments. CPR can handle electronic payments reliably for multiple payment types. A major advantage of automated payments is the ability to receive an 835/ERA with each EFT payment. In addition, EFT payments:

• Increase speed of receiving payments
• Significantly reduce payment processing costs
• Streamline the accounts receivable (A/R) process
• Reduce fraud exposure
• Improve the accuracy and timeliness of information

Here are answers to Frequently Asked Questions about claims payments.

For EFT/ERA enrollment and additional assistance regarding payment, contact ECHO Provider Support at 888-492-0032 or visit their website.

If you have other questions about this process, please sign in to the provider portal at emblemhealth.com/providerportal and use our live agent chat or Message Center to contact us. A Provider Customer Service Representative will be happy to help. 

Our new Weather Resilience Program uses clinical and geographical data to protect those at risk for weather-related illness during events such as the recent heatwave in New York City. We delivered thousands of heat risk alerts to vulnerable members, providing them with personalized heat safety tips, directing them to nearby cooling centers, connecting them to care management support, and even sharing pet safety information. 

To learn more about the program, see the recent LinkedIn post and Forbes article quoting Dr. Dan Knecht, our Chief Medical Officer.

In July 1965, Medicare and Medicaid were signed into law to provide basic health insurance for vulnerable populations. Over the past six decades, these two programs have transformed the U.S. health care landscape, providing affordable coverage and access to care for tens of millions of Americans. 

To mark this milestone, the Health Affairs editors invited EmblemHealth's Karen Ignagni and Andrea Jacobson to share their thoughts on where these programs began, how they’ve changed, and what may lie ahead. Read the full article.

Providers must notify Medicaid of any change of address, telephone number, or other pertinent information within 15 days of the change. For more information on this requirement and how to submit changes, see Reminder: Keep Your Directory Data Current. 

View the latest Medicaid Updates from the New York State Department of Health.

WellSpark Health’s broad range of well-being resources helps our members achieve positive behavioral and lifestyle changes. 

A recent success story is a 47-year-old male member who turned to health coaching for help with managing stress and creating healthy habits and is seeing good results. “My coach asked empathetic questions and inspired me to return to face-to-face, weekly therapy. The therapy and behavior changes I have made have been invaluable and helped me return to a better way of living and I've lost 21 pounds!”

To see which of our benefit plans offer WellSpark’s resources, review the 2025 Summary of Companies, Lines of Business, Networks & Benefit Plans. We ask that you encourage eligible members to sign in to the member portal to see what is available to them and to take advantage of the support offered.

Our EmblemHealth Neighborhood Care locations and ConnectiCare Centers provide one-on-one customer support to help members understand their health plan, provide connections with community resources, and offer free health and wellness events to help the entire community learn healthy behaviors. Our virtual and on-demand events are available to you and all your patients. View locations and upcoming events for EmblemHealth Neighborhood Care and ConnectiCare Centers.

Let Us Know When Directory Information Changes

If a provider in your practice is leaving, please inform us as soon as possible. See how to submit data changes as required by our participation agreements for EmblemHealth and ConnectiCare.

If you participate with us under a delegated credentialing agreement, please have your administrator submit these changes.

Remember to review your CAQH application every 120 days and ensure you have authorized EmblemHealth as an eligible plan to access your CAQH information.

The EmblemHealth Provider Manual is a valuable online resource and an extension of your Provider Agreement. It applies to all EmblemHealth plans and includes details about your administrative responsibilities and contractual and regulatory obligations. You can also find information about best practices for interacting with our plans and how to help our members navigate their health care. A key resource is the Access, Availability, and After-Hours Coverage Standards, which set up the expected time frames for appointment availability, appointment wait times, and after hours coverage. You can find the EmblemHealth Provider Manual in the top navigation menu of our provider website.