Office Visit

The latest Annual Provider Notice is now available. As 2025 comes to an end, now is the time to prepare your practice for the year ahead. Make sure you haven’t overlooked key policy updates, regulatory requirements, or trainings from 2025 that are essential for your participation in 2026.

Also, learn more about our key vendor changes including our switch to DentaQuest Sept. 1, 2025, as our new dental provider replacing HealthPlex, and other important health plan and service updates effective 
Jan. 1, 2026: 

• New York City employees, non-Medicare retirees, and their dependents are being offered the New York City Employees PPO (NYCE PPO) plan, a health insurance plan delivered through a partnership between EmblemHealth and UnitedHealthcare. This plan replaces the GHI Comprehensive Benefits Plan (CBP).
• Prime Therapeutics will replace ExpressScripts, Inc. as our Pharmacy Benefit Manager (PBM) and Utilization Review agent for our pharmacy medical benefits.
• Cigna and First Health/QualCare will be the two wrap network options for plans with out-of-area coverage.  
• ConnectiCare commercial plan members with renewal dates in 2026 will continue to keep their coverage through Molina, ConnectiCare’s parent company. EmblemHealth and ConnectiCare will no longer offer provider network reciprocity for any of their members. This means EmblemHealth providers will no longer see ConnectiCare members seeking in-network care from them. 

Read about our 2026 suite of networks and benefit plans, working with us through our user-friendly provider portal, and our EmblemHealth programs to help your patients find cost-effective and convenient care options.

Here are links to this year’s Annual Provider Notice and other helpful resources:

• 2025-2026 Annual Provider Notice.
• 2026 Summary of Lines of Business, Networks and Benefit Plans.
• 2026 Plans That Do Not Need Referrals (PDF).
• Medicare Advantage Plans.
• Commercial Networks and Benefit Plans.
• State-Sponsored Programs.

Each year, thousands of people in the United States die from the flu, and many more are hospitalized. The flu vaccine prevents millions of illnesses and flu-related visits to the doctor each year. Discuss preventive measures with patients and help prevent getting or spreading the flu.

The flu vaccine is included as a survey question in the annual Consumer Assessment of Healthcare Providers and Systems (CAHPS) evaluation, which examines how satisfied members are with their health plans and prescription drug services. Responses are collected from February through May each year.

Survey Question: “Have you had a flu shot since July 1, 2025?” is one of the questions on the annual CAHPS survey.

Measure adherence is determined by member response via the CAHPS Health Plan Survey.

• Denominator = The number of members with a “Flu Vaccinations for Adults Ages 18–64” who responded “Yes” or “No” to the question “Have you had either a flu shot or flu spray in the nose since July 1, 2025?” on the CAHPS Health Plan Survey. 
• Numerator = The number of members in the denominator who responded “Yes” to the question “Have you had either a flu shot or flu spray in the nose since July 1, 2025?” on the CAHPS Health Plan Survey.

MEASURE DESCRIPTION

The percentage of patients 65 years of age and older who received a flu vaccination between July 1 of the measurement year and the date when the Consumer Assessment of Healthcare Providers Systems (CAHPS) survey was completed.

HOW TO IMPROVE CAHPS SCORES

• Identify an Immunization Champion to lead and monitor flu vaccination efforts at the office.
• Institute a Standing Order Program (SOP) to allow non-physician clinical staff to assess eligibility for vaccination and vaccinate patients, and to educate staff about the SOP.
• Turn on reminders/prompts for the flu vaccine if on electronic medical records (EMR). Review vaccine status in EMR.
• Flag the charts of all patients needing a flu vaccine with a brightly colored sheet if not on EMR.
• Encourage staff vaccination (can also be used to show patients the importance of vaccination).
• Provide members with a list of pharmacy locations if you do not offer the flu vaccine, or visit the NYCHealthMap to help members find providers near them. 
• Address any hesitations the member may have about receiving the flu vaccine. (Examples: Flu vaccines do not cause flu. Flu vaccines aren’t safe.)
• Educate patients that the seasonal flu vaccine protects against the influenza viruses that research indicates will be most common during the upcoming season. Each season requires a different vaccine.

See CDC flu recommendations and educational resources on the CDC website.

We ask that you remind our members with hypertension that EmblemHealth covers automatic blood pressure monitors. There is no member cost-share or preauthorization requirement for members diagnosed with hypertension, provided they meet these coverage criteria.* 

Please discuss how self-monitoring at home may help lower their blood pressure. Members can report their blood pressure verbally during a telehealth (telephone, e-visit, virtual) or office visit.

This is a HEDIS^® measure. This initiative can also help support your blood pressure data capture and the management of your patients, and improve your performance rate for the Quality measure: Controlling Blood Pressure.

Here are recommended steps you can take to help members with hypertension:

• Encourage patients to monitor their blood pressure at home using a digital at-home device.
• Place an order for a blood pressure monitor ONLY through any EmblemHealth contracted pharmacy or contracted DME provider. The cost of the device cannot exceed $40.
• Clearly document in the medical record that the reading was taken by a digital device and the date it was taken. Blood pressure readings taken by a patient using a non-digital device (e.g., manual blood pressure, stethoscope) do not meet criteria. Electronic submission from the device is not required, though it is recommended.

These codes are required for Quality care gap closure:

1. CPT II Code Submission: Submit CPT II codes to reflect the results of the BP reading and improveperformance rate. Adequate control required to meet compliance: BP <140/90 Hg.
   
   1. Systolic Blood Pressure CPT II:
      3074F – blood pressure less than 130 mmHg
      3075F – blood pressure 130-139 mmHg
      3077F – blood pressure greater than or equal to 140 mmHg
      
      
   2. Diastolic Blood Pressure CPT II:
      3078F – blood pressure less than 80 mmHg
      3079F – blood pressure 80‐89 mmHg
      3080F – blood pressure greater than or equal to 90

   For more information on self-monitoring tools and protocols, the CDC has educational materials for members to support Self-Measured Blood Pressure Monitoring | Million Hearts^® (hhs.gov).

    

   *This is an EmblemHealth benefit only for members diagnosed with hypertension.
   

EmblemHealth will observe the 38^th annual World AIDS Day through our commitment to prevent new HIV infections and provide essential services to our members.

In support of this effort, we offer a Care Management program to help our members living with HIV/AIDS. This is a free service that helps members find community resources and navigate the health care system. 

Here are other resources you can use and share with our members:

• NYSDOH Online Resources for Education, Information, and Services: guidance on HIV perinatal prevention, primary and specialty HIV care, and other related HIV treatment topics. 
• CDC HIV PrEP Resources: an online library of HIV resources, including HIV PrEP, which is a preexposure prophylaxis (PrEP). It may protect patients against HIV even if their partner has HIV.

We ask our New York providers to consider registering for inclusion in the New York State Department of Health PrEP Prescribers directory. You can also refer your members to our HIV/AIDS Resources page.

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.

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:

• Dec. 16/18: Ease Your Mind: Coding and Documentation for Behavioral Health and Substance Use Disorders 

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, The Official Health Plan Marketplace 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, extension 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.