July 2026

Featured Stories

At EmblemHealth, our members’ health is our highest priority. This means we stay on top of best practices and adopt the ones we believe can help them get and stay healthy in an affordable way. As part of this ongoing effort, we review how our members get their care. When we find a better way of doing something, we update our policies. You may already know about some of these changes, but we were notified by the New York State Department of Financial Services (DFS) that we did not properly let you know.

Site of Service Medical Policy – Infusions and Injectables Policy

This policy was changed on July 14, 2024, to help our members take advantage of some of the region’s best infusion centers and care offered in their doctor’s office or even in their own homes for injectable and/or intravenous medications that can safely be administered outside of a hospital setting.

EmblemHealth works with multiple organizations that will recommend the most medically appropriate, convenient, and cost-effective options for your EmblemHealth patients.

Prior authorization requests should be submitted to Prime Therapeutics by one of the following methods:

Fax: 888-656-6671
Telephone: 833-519-4548, 8 a.m. to 6 p.m., Monday through Friday
Online: gatewaypa.com

Prime Therapeutics may direct a member to a setting other than the one you and/or they prefer for these services. You have the right to request a real-time clinical peer-to-peer discussion as part of the Prior Authorization process by calling 833-519-4548. If you disagree with Prime Therapeutics decision, you have the right to file an appeal. Prime Therapeutics’ decision will include information about how to file an appeal.

Services the policy covers: Specialty pharmacy infusions and specialty pharmacy injections administered by a health care professional. To see all services the policy covers, view the full Site of Service Medical Policy – Infusions and Injectables Policy.

NY Medicaid, HARP, and Child Health Plus Updates

It is the policy of the New York State Department of Health (NYSDOH) that Medicaid and Health and Recovery Plan (HARP) members receive breast cancer surgery at high-volume facilities. Research shows that five-year survival rates are higher for patients who have breast cancer surgery performed at high-volume facilities. A high-volume facility is one that performs 30 or more mastectomy and lumpectomy procedures annually over a three-year period.

The NYSDOH annually reviews the surgical volumes of all hospitals and ambulatory surgical centers and releases an updated list of low-volume facilities. You can see a list of hospital and ambulatory surgery centers on the NYSDOH website where Medicaid will not pay for breast cancer surgery (effective April 1, 2026).

The policy does not restrict a facility's ability to provide diagnostic or excisional biopsies and post-surgical care (chemotherapy, radiation, reconstruction, etc.).

Preauthorization requests and claims for mastectomies and lumpectomies submitted by these low-volume facilities will be denied. For mastectomy and lumpectomy procedures related to breast cancer, Medicaid/HARP members should be directed to high-volume providers in their area. Any payments issued by EmblemHealth may be subject to recoupment.

It is the policy of the New York State Department of Health (NYSDOH) that Medicaid/HARP members receive breast cancer surgery at high-volume facilities. Research shows that five-year survival rates are higher for patients who have breast cancer surgery performed at high-volume facilities. A high-volume facility is one that performs 30 or more mastectomy and lumpectomy procedures annually over a three-year period.

The NYSDOH annually reviews the surgical volumes of all hospitals and ambulatory surgical centers and releases an updated list of low-volume facilities. You can see a list of hospital and ambulatory surgery centers on the NYSDOH website where Medicaid will not pay for breast cancer surgery (effective April 1, 2026).

The policy does not restrict a facility's ability to provide diagnostic or excisional biopsies and post-surgical care (chemotherapy, radiation, reconstruction, etc.).

Preauthorization requests and claims for mastectomies and lumpectomies submitted by these low-volume facilities will be denied. For mastectomy and lumpectomy procedures related to breast cancer, Medicaid/HARP members should be directed to high-volume providers in their area. Any payments issued by EmblemHealth may be subject to recoupment.

Quality Corner

Our  Transitions of Care (TOC) program helps members with complex care issues better manage their health after a hospital admission. Our team educates them about their condition; shares needed resources and works with them to find the right care to feel better.

Care Management program information is available to our members on the Live Well section of our member website.

To help improve health outcomes, the Transitions of Care Healthcare Effectiveness Data and Information Set (HEDIS^®)measure is included in our Quality Incentive Program (QIP). You can earn incentives and help your patient have a successful transition from hospital to home.

This measure requires one follow-up visit within 30 days of discharge, and for medications prescribed at discharge to be reconciled with outpatient medications in the patient medical record within 30 days of discharge.

Please visit Quality Improvement to learn more about the QIP program from our brochures that provide detailed measure and coding information and helpful tips to ensure you receive credit for providing these services.

HEDIS Tips for Transitional Care visit (TRC)

This measure includes the percentage of patients that received continuity of care following an inpatient discharge, that are 18 years of age or older, who had each of the four components shared below, and completed and documented in the outpatient medical record. The components include Notification of Inpatient Admission, Receipt of Discharge Information, Patient Engagement After Discharge, and Medication Reconciliation Post Discharge.

Notification of Inpatient Admission

Documentation in the outpatient medical records must include evidence of receipt of notification of the inpatient admission with evidence of the date when the documentation was received. It should also be integrated into the appropriate medical record and made available to the primary care provider (PCP) or ongoing provider. Notification and integration must occur on the day of the discharge, through two days after discharge (three days total).

Examples that meet the criteria:

Communication between inpatient providers, hospital staff, emergency department, and the member’s PCP or ongoing care provider regarding admission (like a phone call, email, or fax).
Communication about the admission through a health information exchange, an automated admission, discharge and transfer alert system, or a shared electronic medical record (EMR).
Documentation that the member’s PCP or specialist admitted the member to the hospital.
Communication about the admission from the members health plan.
Documentation that the PCP or specialist placed orders for test and treatments anytime during the inpatient stay.
Documentation of a preadmission exam or planned admission prior to the admission date. The medical record must refer to the planned admission, not documenting just presurgical or pre-op. The time frame for the planned admission is not limited to the day of admission through two days after the admission.
When an emergency room visit results in inpatient admission.
Evidence that the PCP or specialist communicated with the emergency room about the admission.

Receipt of Discharge Information

Documentation in the medical record must include receipt of a discharge, and evidence the information was integrated in the medical record on the day of the discharge through two days after discharge (three days total).

Discharge information can include a discharge summary or summary of care record or be in structured fields in an EMR. It must include the date of receipt and all the following information:

The practitioner responsible for the patient’s care during the inpatient stay.
Procedures or treatments provided.
Diagnosis at discharge.
Current medication list.
Testing results, documentation of pending tests or documentation of no tests pending.
Instructions for patient discharge.

Medical Policies

The following medical policies were updated. See revision history for applicable updates and effective dates.

Medical Necessity Guidelines: Experimental, Investigational or Unproven Services

Breast Reduction Mammoplasty: “Claims of inability to exercise” was removed from Limitations/Exclusions.

Gene Expression Profiling: Positive coverage for dihydropyrimidine dehydrogenase (DPD) deficiency testing to assess risk of, or adverse reactions to, 5-FU chemotherapy was added.

Lyme Disease Intravenous Treatment: Doxycycline added as medically necessary for members intolerant to b-lactam antibiotics.

Pain Management: Added percutaneous electrical nerve field stimulation (PENFS) (e.g., IB-Stim®) as medically necessary).

Also added language to align with a statement released by the American Society of Anesthesiologists (ASA) stating that general anesthesia sedation, and/or monitored anesthesia care (MAC) (CPT codes 01991 and 01992), are not routinely considered medically necessary for interventional pain management procedures.

Home Birth Midwifery Services:

Added the following to the list of high-risk conditions:

Intrauterine growth restriction placental abnormalities (low lying, previa)
Velamentous and marginal cord insertions

Infertility Services — Commercial:

Added “azoospermia or complete lack of motility is noted on semen analysis” RE lack of viable spermatozoa within the Poor Prognosis and Futility Section.
As pertains to IVF cycle protocol, added that two or more embryos may be transferred if no PGT-A testing has been done, and that more than one euploid embryo should not be transferred under any conditions.
As pertains to fertility preservation, added that the creation and cryopreservation of embryos is not covered.
Added teratospermia as a semen parameter for documenting severe male factor infertility.
Added that approval for donor eggs is considered medically necessary until the age of 45 for women with premature ovarian failure.
Added note stating that when donor egg criteria are met, a donor egg cycle is authorized for up to 6 months.

Note: You can see the full list of Medical Policies in Clinical Corner on our website.

Screening	Question	Screening Code	Answer	Finding Code
Housing	What is your living situation today?	71802-3	I have a steady place to live.	LA31993-1
			I have a place to live today, but I am worried about losing it in the future.	LA31994-9
			I do not have a steady place to live. (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park.)	LA31995-6
Food	Within the past 12 months have you been worried that your food would run out before you got money to buy more?	88122-7	Often true	LA28397-0
			Sometimes true	LA6729-3
			Never true	LA28398-8
Transportation	In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?	93030-5	Yes	LA33-6
			No	LA32-8

Search

Popular Tasks

The Bridge Program

Office Visit

Office Visit

Featured Stories

Policy Updates That Impact Where Members Get Care

New Medicare Pilot Program for GLP-1 Starts July 1

New myEmblemHealth Mobile App for Members

Increase Immunization Rates This Summer

New: See Your Offset Reports on the Portal

NY Medicaid, HARP, and Child Health Plus Updates

Restricted Breast Cancer Surgery Facilities

Update: Medicaid and CHPlus Continuous Eligibility for Children up to Age Six

New Deadline for Home Care Worker Wage Parity

State-Sponsored Program News

Update Contact Information When Changes Occur

Claims Corner

One New Reimbursement Policy: Medicaid – NYRx Pharmacy Program

Quality Corner

Get Rewarded for Improving Health Outcomes: Transitions of Care Program

Medicare Updates

Medicare Outpatient Observation Notice (MOON)

Clinical Corner

Updated Preauthorization Lists

Pharmacy

Pharmacy Medical Policies

Medical Policies

Medical Policy Updates

Training Opportunities

NYCE PPO Self-Directed Webinar

Provider Portal Videos and Guides

Valuable Medicare and Medicaid Training Available

Other Provider Training Opportunities

In The News

Helping Our Members Beat The Heat

In Every Issue

EmblemHealth Neighborhood Care

Consult Our Online Provider Manual for Important Information

Consult Our Online Provider Manual for Important Information 