Office Visit

As we have shared over the last year, our provider portals have been enhanced to identify and intake critical information needed to support faster decision making, along with securely accepting larger files to facilitate preauthorizations and concurrent reviews.

The health care industry has a multi-decade history of sending documents by fax. But times have changed and there are faster, more efficient, and more secure ways to share information. Therefore, starting May 1, 2024, we plan to disconnect the fax lines currently in use for preauthorization requests and concurrent reviews.

Those who are currently submitting documents by fax will receive an automatic response to each fax. View an example here. These messages ask that future requests and supporting documentation be sent using the portal and include instructions for obtaining a portal account.

We appreciate your continued support as we work to modernize our systems and improve member and provider experience.

Other Technology Updates
Phone System Now Asks for NPI Not TIN
Our integrated voice response (IVR) systems were recently updated to request the caller’s National Provider Identifier (NPI) rather than their Tax Identification Number (TIN). This will help us better identify our callers and the type of assistance they need.

Please note that the IVR offers self-service options as an alternative to our provider portals. You may check member eligibility and benefits plus the status of a claim, preauthorization, or referral.

Each year we modify our suite of networks and benefits, referral requirements, and various programs. Please review the following materials and share them with your staff and colleagues so you can prepare to see our members in 2024.

• 2023-2024 Annual Provider Notice.
• 2024 Summary of Companies, Lines of Business, Networks, and Benefit Plans.
• 2024 EmblemHealth Plans That Do Not Need Referrals.  
• EmblemHealth Medicare Advantage Plans.
• ConnectiCare Medicare Advantage Plans.
• EmblemHealth Commercial Networks and Benefit Plans.
• Bridge Program.

New federal regulations require EmblemHealth and ConnectiCare provider directories to include each provider’s cultural and linguistic capabilities, including American Sign Language, offered by the provider or a skilled medical interpreter at the provider's office. This important information will improve the quality and usability of provider directories for members in selecting a health care provider.

Effectively immediately, all providers must sign in to the EmblemHealth or ConnectiCare provider portal to update their Provider Profile with “Culture” in the Demographics field, and “Languages” in the Location field. If you participate with us under a delegated credentialing agreement, please have your administrator submit these updates.

Beginning Jan. 1, 2024, members in all HMO products will no longer be automatically assigned to your practice in the last two years, or remain attributed to you, unless they choose you as their primary care provider (“PCP”) or if a claim shows they have been cared for by a PCP in your practice.

The previous policy, effective Jan. 1, 2023, allowed for PCPs to keep commercial and Medicare auto-assigned members regardless of whether the provider saw these members.

Medicaid members were previously automatically assigned select provider groups. To be consistent with state policy, Medicaid members will now be automatically assigned to provider groups based on demographic and location needs beginning in 2024.

Members for all lines of business will be attributed to your panel as of the date they chose you as their PCP. These members will remain paneled to your practice regardless of the utilization reporting process outlined below since they actively chose you as their PCP of record. For those members who did not actively chose you as their PCP, the following process applies:

• EmblemHealth will run a monthly claims utilization report for members in all lines of business with no assigned PCP to check for preventive visits, other evaluation and management (E&M) PCP visits, lab services referred by PCP, and prescriptions written by a PCP. If they have utilization with any of your PCPs, EmblemHealth will assign that member to your group as of the first of the month.  

• A quarterly claims utilization report will be run by EmblemHealth to check utilization for all members currently assigned to PCPs for all lines of business. If members continue to use PCPs in your practice, then they will remain with your group. If, however, your members have been cared for by a different PCP, they will be assigned to that PCP starting on the date of that PCP visit.

In the event a member does not have utilization with any PCP, in your group or otherwise, they will no longer be attributed to your practice.

• Capitation payments will be impacted by these changes, and recoupments and additional payments may be initiated, as applicable.

By implementing this new PCP assignment process, we aim to support proactive patient engagement and foster of good provider-patient relationships.

Assisting members with their PCP selection in this manner helps to facilitate any possible clinical care coordination, should it be necessary, and helps empower the member to achieve better overall wellness. We believe this change will help connect our members to the quality health care you provide and enable insights that accurately reflect the members whose care you manage.

We all play an important role impacting member experience that is captured every year through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.

This survey measures the patient’s perception of their health plan and their doctor. High CAHPS survey scores reflect positive relationships between our members and providers and their ability to access timely, well-coordinated care.

Your interaction with patients has a direct impact on their response to the CAHPS survey. Here are some tips to provide exceptional patient care:

• Two-way communication: Communicate in plain language. “Have you had a flu shot since July 1, 2023?” is one of the CAHPS questions. Remind your patients to get a flu vaccine.
• Explain the care provided and 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 hours, and virtual visits.
• Equip patients with tools such as materials about health conditions. Implement reminder systems and let members view their health records.
• 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 non-urgent sick visits within 48 to 72 hours of the member’s request.

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