Your source for important provider news and updates.
October 2025
IN THIS ISSUE
FEATURE STORIES
Coming Jan. 1: New Plan for City Employees
Clinical Practice Guidelines
November Is Diabetes Awareness Month
Nov. 8 Is Lung Cancer Screening Day
MEDICARE UPDATES
Medicare Outpatient Observation Notice (MOON)
NY MEDICAID, HARP, AND CHILD HEALTH PLUS UPDATES
PCP Teams May See Foster Care Members
Change of Address and Contact Notification
New York State Medicaid Update
CLAIMS CORNER
Reimbursement Policies
Reminder: CPT and HCPCS Billing Guidelines
CLINICAL CORNER
Preauthorization Updates
MEDICAL POLICIES
Medical Policy Updates
TRAINING OPPORTUNITIES
Provider Portal Videos and Guides
Free Patient Management and ICD-10 Coding Webinars
Valuable Training Available
IN EVERY ISSUE
EmblemHealth Neighborhood Care
Keep Your Directory and Other Information Current
Consult EmblemHealth’s Online Provider Manual for Important Information
Feature Stories
Coming Jan. 1: New Plan for City Employees
As you should have read in an email from EmblemHealth earlier this month, New York City employees, pre-Medicare retirees, and their dependents will be offered the New York City Employees PPO (NYCE PPO) plan, a health insurance plan delivered through a partnership between EmblemHealth and UnitedHealthcare. This plan launches Jan. 1, 2026.
We have a website for providers and will be publishing updates there, but will also use this newsletter to remind our network in these final 11 weeks before launch.
Please become familiar with this plan as there are geographic requirements that may impact your participation. The email and website both provide more details as well as what your practice can do now to ensure you can see NYCE PPO members after Jan. 1.
Clinical Practice Guidelines
Providers are encouraged to consult our Clinical Practice Guidelines for assistance in the treatment of acute, chronic, and behavioral health issues.
The following 14 guidelines were updated to reflect current recommendations and guidelines for prevention, treatment, and management of certain medical conditions:
Chronic Kidney Disease
Chronic Pain
Congestive Heart Failure
Low Back Pain Diagnosis and Treatment
Stroke Prevention
Urinary Incontinence
Cholesterol Management for Adults at Risk for Cardiovascular Disease
Diabetes Mellitus
Obesity and Weight Management in Adults
Obesity and Weight Management in Children and Adolescents
Appropriate Use of Antibiotics for Adults and Children
Preconception Care
Prenatal/Postpartum
AIDS/HIV
Clinical Practice Guidelines are not intended as a substitute for the professional assessment of the health care practitioner. They are put in place to help manage certain types of preventive and clinical care.
November Is Diabetes Awareness Month
The American Diabetes Association has provided recommendations to help people living with diabetes manage their condition and improve their health.
Here are some recommended preventive screenings for your patients with diabetes:
Information is also available to assist with coding guidance for Quality gap in care closure. Please visit Quality Improvement on our website and download the Quality Measure Resource Guide for more information.
Nov. 8 Is Lung Cancer Screening Day
Ten years have passed since the U.S. Preventive Services Task Force (USPSTF) first recommended low-dose CT for lung cancer screening, yet lung cancer screening rates remain low, with less than 1 in 10 eligible individuals having undergone CT screening.
November is a good time to encourage your patients to get screened for lung cancer. The American Cancer Society and USPSTF recommend yearly lung cancer screening with a low-dose CT scan for current and former heavy smokers ages 50 and older.
Find valuable resources sponsored by the American Cancer Society to support your patients’ screening here:
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.
NY Medicaid, HARP, and Child Health Plus Updates
PCP Teams May See Foster Care Members
As an EmblemHealth network provider, you may be responsible for providing primary care services for children/youth who are Medicaid members in direct placement foster care and in the care of Voluntary Foster Care Agencies (VFCAs), even if you are not the assigned primary care provider (PCP) on the member’s ID card.
As a reminder, New York State Medicaid allows PCP teams to provide care to Medicaid members. Any PCP at a practice can see the foster care member should the assigned PCP on their member ID card not be available at the scheduled appointment.
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.
New York State Medicaid Update
View the latest Medicaid Updatesfrom the New York State Department of Health.
Claims Corner
Reimbursement Policies
Starting Jan. 1, 2026, EmblemHealth and ConnectiCare are introducing Nutritional Counseling Services Reimbursement Policies. Refer to the website applicable to the member’s plan (EmblemHealth | ConnectiCare) to see the relevant policy.
The following reimbursement policies have been updated for both EmblemHealth and ConnectiCare. Refer to the website applicable to the member’s plan (EmblemHealth | ConnectiCare) and see the revision histories for effective dates and applicable changes.
EmblemHealth
EmblemHealth DME Rental vs. Purchase Reimbursement Policy
EmblemHealth Free Flap Breast Reconstruction
EmblemHealth Procedure/Surgery Performed in Physician’s Office (Facility & Equipment) formerly known as Modifier SU – Procedure Performed in Physician’s Office (Commercial)
EmblemHealth Preventive Care Services (Commercial and Medicaid) Reimbursement Policy
EmblemHealth Preventive Care Services (Medicare) Reimbursement Policy
ConnectiCare
ConnectiCare DME Rental vs. Purchase Reimbursement Policy
ConnectiCare Free Flap Breast Reconstruction
ConnectiCare Procedure/Surgery Performed in Physician’s Office (Facility & Equipment) formerly known as Modifier SU – Procedure Performed in Physician’s Office (Commercial)
ConnectiCare Preventive Care Services (Commercial) Reimbursement Policy
ConnectiCare Preventive Care Services (Medicare) Reimbursement Policy
Reminder: CPT and HCPCS Billing Guidelines
Please remember that EmblemHealth and ConnectiCare do not accept most HCPCS codes on claims for medical, surgical, and/or diagnostic procedures for our commercial and Medicaid plans. Instead, providers should submit claims with the appropriate CPT code(s) that accurately identify the procedure(s) and/or service(s) performed.
Free Flap Breast Reconstruction
EmblemHealth and ConnectiCare require providers to submit CPT code 19364 to report breast reconstruction via a free flap. We do not accept HCPCS Level II S2066-S2068. To help with proper coding, we have updated our reimbursement policy to include a clarifying example regarding Free Flap Breast Reconstruction (HCPCS codes S2066-S2068).
The history behind the codes explains why we need our providers to use CPT code 19364. At a time when there was no national code to adequately describe free flap breast reconstruction, the Blue Cross/Blue Shield association developed the temporary HCPCS Level II codes S2066-S2068. Since the development of the temporary “S” codes, the AMA updated CPT code 19364 to describe free flap breast reconstruction via the techniques described in S2066-S2068 (GAP, DIEP, and SIEA flaps). Therefore, EmblemHealth and ConnectiCare do not accept HCPCS Level II S2066-S2068 to report breast reconstruction via a free flap and require providers to submit CPT code 19364 instead.
If you still have questions or need additional support, contact Provider Customer Service using the provider portal’s Message Center or live agent chat.
Free Patient Management and ICD-10 Coding Webinars
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:
Oct. 28/30: Arm Yourself: Battling Through Coding and Documentation for Cancer
Nov. 18/20: Fill Your Plate with Knowledge: Coding and Documentation for Gastroenterology
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.
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.
Our EmblemHealth Neighborhood Care locations provide one-on-one customer support to help members understand their health plan, provide connection to community resources, and offer free health and wellness events to help the entire community learn healthy behaviors. Our virtual and on-demand events are available to you and all your patients. View locations and upcoming events for EmblemHealth Neighborhood Care.
Keep Your Directory and Other Information Current
Let Us Know When Directory Information Changes
If a provider in your practice is leaving, please inform us as soon as possible. See how to submit data changes as required by our participation agreements for EmblemHealth and ConnectiCare.
If you participate with us under a delegated credentialing agreement, please have your administrator submit these changes.
Remember to review your CAQH application every 120 days and ensure you have authorized EmblemHealth as an eligible plan to view your CAQH information.
Consult EmblemHealth’s Online Provider Manual for Important Information
The EmblemHealth Provider Manual is a valuable online resource and an extension of your Provider Agreement. It applies to all EmblemHealth plans and includes details about your administrative responsibilities and contractual and regulatory obligations. You can also find information about best practices for interacting with our plans and how to help our members navigate their health care. A key resource is the Access & Availability Standards, which set up the expected time frames for appointment availability, appointment wait times, and after-hours coverage. You can find the EmblemHealth Provider Manual in the top navigation menu of our provider website.
Some key resources are the Access, Availability, and After-Care Hours Coverage Standards, which set up the expected time frames for appointment availability, wait times, and after-hours coverage. The manual also has instructions for requesting interpreter services for more than 200 languages, including sign-language for the speech and hearing impaired, services for the visually impaired, and resources to assist you in caring for children with special needs.
We use cookies on this website to give you the best experience and to measure website usage. By continuing to use this website, you consent to these cookies. View our Privacy Policy here.