EmblemHealth Provider Site
IN THIS ISSUE
FEATURE STORIES
May Is Mental Health Awareness Month
May 14 to 20 is Women’s Health Week
MD PERSPECTIVES
MD Perspectives: Sandra Rivera-Luciano, MD
MEDICARE UPDATES
Medicare Outpatient Observation Notice (MOON)
NY MEDICAID, HARP, AND CHILD HEALTH PLUS UPDATES
Project TEACH: Maternal Mental Health Services
Change of Address (and Contact) Notification
Medicaid: New York State Medicaid Update
CLAIMS CORNER
Reimbursement Policy Updates
CLINICAL CORNER
Preauthorization List Updates
Beacon Health Options Is Now Carelon Behavioral Health
PHARMACY
Resources To Help Improve Medication Adherence
Reminder: New Claims Process for Medicare Part D Vaccine Billing
MEDICAL POLICIES
Revised Medical Policies
TRAINING OPPORTUNITIES
Provider Portal Videos and Guides
Free Patient Management and ICD-10 Coding Webinars
Valuable Training Available
IN EVERY ISSUE
Let Us Know When Directory Information Changes
Consult EmblemHealth’s Online Provider Manual
EmblemHealth Neighborhood Care and ConnectiCare Centers
Feature Story
May Is Mental Health Awareness Month
For Mental Health Awareness Month, we want to highlight the importance of coordination between behavioral health care providers and medical care providers to ensure appropriate care for patients with mental health and substance use disorders.
Caring for your patients’ mental health is important to their overall health. We are here to help you understand and address their health care needs. We remind you to look for signs of mental illness when providing care and refer patients for behavioral health services, if needed. Resources to help support mental health awareness are available to you here:
EmblemHealth Behavioral Health | ConnectiCare Behavioral Health
Medical care professionals can help address and coordinate behavioral health care by:
- Screening for mental health conditions.
- Talking about the medicines your patients take to help avoid potentially harmful medication reactions.
- Encouraging and coordinating seven-day follow-up care after mental health related ED/IP admission.
- Helping to link members to behavioral health specialist, if needed.
We Are Here To Help
Share this information with our members who have questions or need help finding a behavioral health professional:
EmblemHealth members: Call Carelon (formerly Beacon Health Options) at 888-447-2526 (TTY: 711). A representative can help 24 hours a day, seven days a week.
ConnectiCare members: Call Optum at 888-946-4658 (TTY: 711). A representative can help 24 hours a day, seven days a week.
Neighborhood Care: EmblemHealth members can stop by any of our Neighborhood Care locations for community support. Visit emblemhealth.com/neighborhood.
May 14 to 20 is Women’s Health Week
National Women’s Health Week begins on Mother’s Day, May 14. It’s a great opportunity to encourage your patients to make their health a priority.
Women are typically the cornerstone of a family’s overall health. Those who are caregivers have a greater risk for poor physical and mental health. According to the Centers for Disease Control and Prevention (CDC), two out of every three caregivers in the United States are women. Ensuring that they have access to quality care can lead to improved health for the whole family.
The CDC offers tips on what you can do to support your female patients.
MD Perspectives
Sandra Rivera-Luciano, MD
Hello, colleagues.
Although Edward Bulwer-Lytton famously said that the pen is mightier than the sword, we find that a one-on-one conversation with a colleague can be even more effective.
That’s why we created our Peer-to-Peer (P2P) process – to allow for these conversations to address adverse determinations. As physicians, both in the community and within our health plan, we can discuss and collaborate on the right path forward for your patients. See more.
Sandra
Sandra Rivera-Luciano MD, MHSA, FAAP
Sr. Medical Director/Utilization Management
Would you like our perspectives on other health topics? Please write to us at
emblemhealthmedicaldirectors@emblemhealth.com.
While we welcome your suggestions, we ask that you do not send protected health information (PHI) or patient-specific issues to this mailbox. This mailbox should not be used for complaints, grievances, appeals, or claims inquiries. The Claim Inquiry and Message Center features in the provider portals (EmblemHealth | ConnectiCare) should be used for those issues.
Medicare Updates
Medicare Outpatient Observation Notice (MOON)
The Centers for Medicare & Medicaid Services (CMS) requires hospitals, including critical access hospitals (CAHs), to give written and verbal notice of receiving outpatient observation services of more than 24 hours to Medicare beneficiaries, including Medicare Advantage enrollees. All hospitals and CAHs must use the updated version of the Medicare Outpatient Observation Notice (MOON) (CMS-10611) no later than April 27, 2023. The notice is available for download.
NY Medicaid, HARP, and Child Health Plus Updates
Project TEACH: Maternal Mental Health Services
Training and Education for the Advancement of Children’s Health, known as Project TEACH, is a statewide program that supports reproductive, primary care, and pediatric clinicians in delivering quality mental health care in New York State. This program strives to strengthen and support the delivery of care to children, families, and individuals who experience mental health concerns during the perinatal period.
Change of Address (and Contact) Notification
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.
Medicaid: New York State Medicaid Update
View the latest Medicaid Updates from the New York State Department of Health.
Claims Corner
Reimbursement Policy Updates
The following reimbursement policies have been updated. See the Revision History sections of each policy to see the applicable changes and effective dates.
- Lab Venipuncture Policy (EmblemHealth | ConnectiCare)
- Coding Edits Policy (ConnectiCare)
Clinical Corner
Preauthorization List Updates
The following preauthorization lists have been updated to remove codes effective April 1, 2023:
EmblemHealth – See Notable Changes for the 149 codes removed from the list. Also see CPT 76948, “Ultrasonic guidance for aspiration of ova, imaging supervision, and interpretation,” being added to the list starting July 14, 2023.
ConnectiCare Commercial – See revision history for the 137 codes being removed.
ConnectiCare Medicare – See revision history for the 116 codes being removed.
Beacon Health Options Is Now Carelon Behavioral Health
Beacon Health Options has been renamed to Carelon Behavioral Health. Their new website is carelonbehavioralhealth.com but nothing changes about our members’ access to care. Please review the EmblemHealth Provider Manual’s Behavioral Health chapter if you need a refresher on what’s offered and how to connect to these services.
Pharmacy
Resources To Help Improve Medication Adherence
Continued adherence to a prescription drug regimen is essential to achieve the desired therapeutic outcome for your patients. There are several resources available in different languages on both EmblemHealth’s and ConnectiCare’s medicine adherence webpage that can be shared with your patients.
Helpful tips to increase medication adherence:
- Switch patients from 30-day to 90-day refills for medicines for chronic conditions.
- Avoid “polypharmacy” by keeping a current medicine list. EmblemHealth and ConnectiCare offer free fillable/printable medication lists in different languages for medication adherence.
- Encourage the use of a pill box or some sort of compliant packaging. EmblemHealth and ConnectiCare offer free pill boxes that can be shipped to the patient.
- EmblemHealth Pharmacy Services, 866-340-0099 (TTY: 711), and ConnectiCare Pharmacy Services, 800-828-3407 (TTY: 711), can help with questions regarding:
- Deductible or copay questions and preferred alternatives.
- Preauthorizations.
- Coverage checks, test claims, and coverage gaps.
- Patient assistance programs such as a manufacturer discount card.
- Creating help desk tickets for further assistance.
Reminder: New Claims Process for Medicare Part D Vaccine Billing
Starting May 16, 2023, Medicare Part D vaccine claims should be submitted to TransactRx at transactrx.com/physician-vaccine-billing.
As announced in the February 2023 edition of Office Visit, the Part D Vaccine Billing Guidelines (Medicare) Reimbursement Policy that has been in effect for ConnectiCare will also apply to EmblemHealth. Consistent with guidance from the Centers for Medicare & Medicaid Services (CMS), EmblemHealth and ConnectiCare will not reimburse claims for Part D vaccines administered in the physician’s office and submitted under the Part B medical benefit.
Medical Policies
Revised Medical Policies
The following medical policies have been revised for both EmblemHealth and ConnectiCare:
- Bariatric Surgery — Added pediatric criteria. (EmblemHealth | ConnectiCare).
- Infertility Services — Added non-coverage of uterine transplant for the treatment of uterine factor infertility to the list of Limitations/Exclusions. Added clarifying edits to “General indications,” “General infertility surgery,” and “Noncovered services.” (EmblemHealth | ConnectiCare).
- Osteochondral Grafting — Added patellar chondral defect indication to coincide with covered diagnostic coding. (EmblemHealth | ConnectiCare).
- Rhinoplasty — Removed the photo documentation prerequisite. (EmblemHealth | ConnectiCare).
The following EmblemHealth medical policies are being retired:
- Genetic Counseling and Testing.
- Outpatient Cardiac Rehabilitation.
- Supervised Exercise Therapy for Symptomatic Peripheral Artery Disease.
Training Opportunities
Provider Portal Videos and Guides
If you need help navigating our provider portals, our videos, quick guides, and frequently asked questions (FAQs) pages can help.
In the last edition, we announced that the attachment file size for supporting documentation file uploads in the provider portal increased to 25MB. This applies to preauthorizations only at this time. The size for all other transactions is 5MB. We will provide an update as soon as it becomes available.
EmblemHealth Videos and Guides
ConnectiCare Videos and Guides
Contact Provider Customer Service if you still have questions or need additional support:
EmblemHealth: 866-447-9717
ConnectiCare: Commercial: 860-674-5850, Medicare: 877-224-8230
Free Patient Management and ICD-10 Coding Webinars
EmblemHealth works with Veradigm to offer free monthly webinars to help educate providers on best practices regarding the risk adjustment process. This includes accurate medical record documentation and claims coding to capture the complete health status of each patient.
EmblemHealth also works with Veradigm to promote risk adjustment and gap-closure education for primary care providers (PCPs) caring for EmblemHealth members enrolled in these products:
- New York State of Health (NYSOH) Marketplace.
- Medicare HMO.
- Medicaid.
The Veradigm webinars are held on Tuesdays and Thursdays, with one session in the morning and one in the afternoon to accommodate all schedules. Here are the April and May topics:
- April 25 and 27 – Don’t Be Fooled … Social Determinants of Health are Key Factors for Your Patient Population*
- May 23 and 25 – Blooming into the Comprehensive Evaluation of Neurological Disorders
To register, go to our Online Learning > Veradigm Webinars web page to scan topics and dates. Click the Registration button at the bottom, then the Public Event List link and search by webinar date or title of interest.
If you have any questions, or you would like to set up a private session for your practice, email Veradigm at providerengagement@veradigm.com or call Veradigm's Customer Support team at 410-928-4218 (option 7), available Monday through Friday from 8 a.m. to 8 p.m.
*You can also see our own medical director’s perspective on population health and the social determinants of health.
Valuable Training Available
We recommend that you take advantage of the training opportunities offered by CMS’s Medicare Learning Network and eMedNY.
In Every Issue
Let Us Know When Directory Information Changes
If a provider in your practice is leaving, we ask that you inform us as soon as possible. To report other changes, sign in to your Provider/Practice Profile for EmblemHealth or ConnectiCare. If you participate with us under a delegated credentialing agreement, please have your administrator submit these changes. See more on how to submit changes for EmblemHealth and ConnectiCare.
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. You can find the EmblemHealth Provider Manual on top right side of our website.
EmblemHealth Neighborhood Care and ConnectiCare Centers
Our EmblemHealth Neighborhood Care and ConnectiCare Centers 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 and ConnectiCare.
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