Office Visit

The new year is right around the corner. This year’s annual provider notice has everything you need to prepare for working with us in 2026, including guidance on: 

• Caring for our City members under the New York City Employees PPO (NYCE PPO) plan. Note: NYCE PPO will use The Bridge Program to give members the broadest access to care from providers in 13 downstate New York counties; UnitedHealthcare’s Choice Plus Network provides access to care everywhere else.
• 2026 changes to our networks and benefit plans.
• New relationships for out-of-area care, pharmacy management, and pharmacy medical benefit utilization review.

You can also look back at updates and regulatory requirements you may have missed in 2025, to prepare you and your practice for the year ahead. 

If you have not attended a Prime Therapeutics training yet, sign up to get familiar with our new pharmacy medical benefit utilization management program. 

Choose a session that works best for you and register at one of the links below:

• Session 3: Dec. 17 at 10 a.m.
• Session 4: Dec. 17 at 2 p.m.

In case you missed it in last month’s edition of Office Visit, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey season is here. We all play an important role in shaping the member experience that is captured each year through CAHPS.

High CAHPS survey scores reflect positive relationships between providers and our members, and their ability to get timely, well-coordinated care. The survey questions are also a great way to make sure your patients take care of their health, including reminding them to get their flu vaccine this holiday season. Earlier in the season, we also emailed members to remind them to make an appointment for a flu vaccine. 

As a provider, you are on the front lines of the patient experience, and your interaction has a direct impact on their responses to the CAHPS survey. 

Here are some tips to help you provide exceptional patient care for our members:

• Two-way communication: Communicate in plain, easy-to-understand language. “Have you had a flu shot since July 1, 2025?” is one of the CAHPS questions. Remind your patients the importance of getting a flu vaccine.
• Equip patients with tools such as materials about health conditions. Implement reminder systems and let members view their health records.
• Explain the care provided and the proposed treatment plan in ways that are easy to understand. Listen carefully. Make sure patients also understand the care they receive from other providers.
• Assess the need for increased appointment availability. Consider offering same-day appointments, evening and weekend appointments, a nurse line after office hours, and virtual visits.
• Consider timeliness. Limit telephone hold times to under 15 minutes, and keep patients informed if you are running behind schedule. Try to schedule well visits/routine physicals within four weeks, and nonurgent sick visits within 48 to 72 hours of the member’s request.

Visit our Clinical Corner for more details and to find out how to improve your CAHPS scores.

More than 13,000 women in the United States are diagnosed with invasive cervical cancer each year. However, vaccination and appropriate screening can help prevent this disease and increase the rate of early detection. There is no single solution to ending cervical cancer, but together, we can help close gaps in care for our members. 

Steps for closing care gaps:

1. Use the Gap in Care report to identify patients who need to be scheduled for a wellness visit or to identify patients who are not compliant for this measure. To see who is noncompliant, filter for measure name and ‘noncompliant’ using the ‘Compliant Status’ column.
2. During the visit:
   • Highlight the importance of early detection.
   • Review barriers.
   • Stress importance of yearly screening.
3. Place reminders in patients’ charts for when their next screening is due and make reminder calls for scheduling follow-up calls and visits.
4. Flag the patient’s chart after screening is performed to ensure the data is captured for compliance and timely follow-up of the results takes place.
5. Ask to have cervical cytology results sent to you if they are done at an OB/GYN office.

See  EmblemHealth Clinical Practice Guidelines and the latest guidance from the American Cancer Society that was just released Dec. 4, 2025.

Actions needed for compliance:

Cervical cancer screening for women 21 to 64 years of age, following the required timeframe:

• ·Women 21 to 64 years of age: Cervical cytology during the current year or two years prior to the current year (every three years).
• Women 30 to 64 years of age: Cervical high-risk human papillomavirus (hrHPV) testing performed during the current year or four years prior to the current year (every five years).
• Women 30 to 64 years of age: Cervical cytology/HPV co-testing during the current year or four years prior to the current year (every five years).

Documentation and coding requirements 

Documentation of date (month, year) cervical cytology was performed and results or findings. Use correct billing codes and ensure timely submission of claims: Cervical cytology CPT: 88141 – 88143, 88147, 88148, 88150, 88152 – 88164 – 88167, 88174, 88175. HCPCS: G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091. HPV test CPT: 87624, 87625. HCPCS: G0476.

The Medicaid payment policy Ambulatory Patient Group Weight Adjustment to Dialysis Clinics for Phosphate Binder Costs that bundled phosphate binders into the dialysis clinic APG rate for Medicaid-only patients has been delayed until Jan. 1, 2026. Dialysis patients can continue to have prescriptions for phosphate binders filled at a New York State Medicaid pharmacy (NYRx) until Jan. 1, 2026. 

Starting Jan. 1, 2026, phosphate binder prescription drugs for dialysis patients will no longer be covered as a pharmacy benefit and must be provided by the dialysis clinic. Dialysis patients should not be referred to a pharmacy to obtain phosphate binders. 

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 Information Current.

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