Office Visit

EmblemHealth is committed to helping our Medicare population manage their medication costs. 

Starting Aug. 18, 2025, when we identify potential cost-saving prescriptions for our members, we will fax the member’s information and the cost-saving alternative(s) to the prescribing provider for consideration. 

The prescriber will need to review, complete, and fax the attached form back to us to authorize the recommended change or indicate why the switch is not appropriate.  

Exception for controlled substances

To accept the recommended change for a controlled substance, the prescriber will need to both fax the authorization order form back to us AND send the prescription change via electronic health record directly to the member’s pharmacy. 

By the year 2030, adults aged 65 and older are projected to outnumber children for the first time in U.S. history.

Promoting health and preventing disease in older Americans is key to the nation’s health. As we age, physical and cognitive function may decline, and pain may affect quality of life. Older people may also have more complex medication regimens.

Here are some best practices to consider for your 65-and-over patients:

• Incorporate a standardized checklist to capture functional status, pain status, and any medications the member may take.
• Complete a functional status assessment and pain assessment at every face-to-face and telehealth visit.
• Ensure the medical record contains the member’s medication list.
• Document in the medical record if the member is not taking any medication.

The Centers for Disease Control and Prevention’s (CDC) Still Going Strong campaign speaks directly to older adults and their caregivers. Resources are available to download and share. Please also see information about EmblemHealth’s free Care for the Older Adult program.

Raising awareness about preventable injuries among older adults and simple steps people can take to stay healthy and independent longer can be found in the campaign. Getting older doesn’t mean your patients have to give up the activities they enjoy.

We announced last month that the OrthoNet portal for preauthorization requests for EmblemHealth's Spine Surgery and Pain Management Therapies Program would be discontinued and a new Optum portal would be used. Since then, we received an update from OrthoNet that this transition has been postponed.

The Sept. 3, 2025, migration date is no longer in effect. The OrthoNet portal will remain active until further notice. We will notify you once a new go-live date is confirmed. In the meantime, please continue to use the OrthoNet portal for all applicable prior authorization submissions.

• One Healthcare ID: Providers who have already transitioned to using a One Healthcare ID for the OrthoNet portal can continue using their existing credentials when the new portal goes live in the future. No new login is required at this time.
• Address Changes to Letter Templates: The planned address change to Optum, P.O. Box 5600, Kingston, NY, 12402-5600 is also postponed and will take effect with the new go-live date.

You will continue to receive paper copies of determinations and non-determination letters until the new portal goes live. 

See previous announcement.

EmblemHealth and ConnectiCare update their claims processing systems based on code updates received from American Medical Association (AMA), CPT^® and CMS. Both the AMA and CMS release quarterly updates to their respective code sets. Below are links to the latest preauthorization lists.

We strive to load and configure each code update within 60 days of the update’s effective date. The current process holds the entire claim if it contains a new code while it is being configured. To avoid delaying critical payments to our providers, we adjudicate the claim for all services except for the new code(s) that need configuration. Once the new CPT and/or HCPCS codes have been loaded into our claims processing system, we will reprocess the claims to ensure proper adjudication of the claim.

EmblemHealth Preauthorization List: See list for code changes and applicable effective dates.

 See revision histories for updates to the following lists:

• GHI PPO City of New York Preauthorization List.
• ConnectiCare Commercial Preauthorization List.
• ConnectiCare Medicare Preauthorization List.
• EmblemHealth/ConnectiCare Home Infusion Therapy Drug Preauthorization List.
• The Pharmacy Medical Preauthorization Lists for EmblemHealth and ConnectiCare.

Clarification: Telehealth cannot be used for the HEDIS Well-Child visit measure but may be submitted for other medical record reviews. 

See original announcement.

The Centers for Medicare & Medicaid Services (CMS) requires all hospitals and critical access hospitals to provide Medicare beneficiaries, including Medicare Advantage enrollees, with the Office of Management and Budget approved Medicare Outpatient Observation Notice (MOON). Visit CMS for details on MOON and instructions for completing notices.

If you need help navigating our provider portals, please see our videos, quick guides, and Frequently Asked Questions pages: 

• EmblemHealth Videos and Guides.
• EmblemHealth Frequently Asked Questions.
• ConnectiCare Videos and Guides.
• ConnectiCare Frequently Asked Questions.

If you still have questions or need additional support, contact Provider Customer Service using the provider portal’s Message Center or live agent chat.

EmblemHealth works with Veradigm to offer free monthly webinars to help educate providers on best practices for the risk adjustment process. This includes accurate medical record documentation and claims coding to capture the complete health status of each patient.

The Veradigm webinars are held on Tuesdays and Thursdays; one in the morning and one in the afternoon. View topics and dates here. Click the Register button, then the Public Event List link, and search by webinar date or title of interest.

Here are the upcoming topics:

• Aug. 26/28: Don’t Let Coding Get Under Your Skin: Coding and Documentation for Dermatology Disorders
• Sept. 23/25: Making Connections: Proper Coding and Documentation for Neurological Conditions

EmblemHealth also works with Veradigm to promote risk adjustment and gap-closure education for primary care providers caring for EmblemHealth members enrolled in these products:

• NY State of Health plans.
• Medicare HMO.
• Medicaid.

If you have any questions, or you would like to set up a private session for your practice, please email Veradigm at providerengagement@veradigm.com or call Veradigm's Customer Support team at 410-928-4218, option 7, from 8 a.m. to 8 p.m., Monday through Friday.

We recommend that you take advantage of the training opportunities offered by CMS’ Medicare Learning Network and eMedNY.