Office Visit

EmblemHealth has achieved a nearly 38% improvement in key pharmacy quality measures within our Medicare Dual Eligible Special Needs Plan (D-SNP), earning the company the 2025 Pharmacy Quality Alliance (PQA) Quality Improvement Award. Read more.

June 27 is National HIV Testing Day. This annual recognition serves as a reminder to talk to your patients about being tested for HIV. 

According to the Centers for Disease Control and Prevention (CDC), HIV testing is the pathway to engage people in their care. When patients are aware of their HIV status, it can help them choose options to stay healthy, regardless of their test results.

Here’s a video from the Centers for Disease Control and Prevention focused on clinicians having a discussion about HIV testing with their patients.

We know some of our network providers who are seeing ConnectiCare members may have questions about their role following the Feb. 1, 2025 acquisition of ConnectiCare by Molina Healthcare. 

Depending on their benefit plan, ConnectiCare members may be able to see EmblemHealth providers. We ask you to be aware of which plans have this EmblemHealth/ConnectiCare reciprocity (last column in 2025 Summary of Companies, Lines of Business, Networks, and Benefit Plans). In these cases, continue to follow current ConnectiCare processes and procedures. Additionally, Molina shared these Frequently Asked Questions with ConnectiCare providers to address key issues.

We appreciate your collaboration through this transition.

Well-Child Visits (WCV)
You can conduct or schedule well-child visits when patients come to your office for illnesses or other events. You don’t need to wait 365 days between well visits. This means children no longer must wait 12 months from the date of their last wellness visit to be covered for an annual wellness visit. The claim modifier for separate and distinct services should be added. Telehealth can be used for well-child visit compliance but be sure to submit the appropriate CPT with GT modifier. 

This measure is based on the American Academy of Pediatrics Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents (published by the National Center for Education in Maternal and Child Health). Visit Bright Futures for more information about well-child visits.

Oral Evaluation, Dental Services (OED)
When seeing your pediatric patients, talk to their families about the link between oral and overall health, and encourage routine dental visits beginning as early as age one, or first tooth eruption. 

• No referral is required to see a dental provider.
• Inform the family of the link between oral health and overall health.
• Encourage routine visits beginning as early as age one or first tooth eruption.

Regular checkups are important at all ages, so be sure to schedule annual wellness visits for all your patients.

As of April 1, 2025, EmblemHealth began covering doula services in hospital, clinic, and community settings for Medicaid, Health and Recovery Plan (HARP), and Essential Plan members who are pregnant, birthing, and postpartum (for up to 12 months after the delivery date). See Improving Health Outcomes With Doula Services | EmblemHealth.

The Medicaid Health Home program is a free care management program offered by the New York State Department of Health to help eligible people stay as healthy as they can. Please share this flyer What is a Health Home? with your patients.

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. 

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.

The “Limitations/Exclusions” sections of EmblemHealth’s Medical Necessity Guidelines: Experimental, Investigational or Unproven Services and ConnectiCare’s Experimental Investigational or Unproved Services Policy were updated to include hyperlinks to related Clinical Trial Medical Policies.