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When we introduced our current claims system several year ago, Commercial and Medicare members were issued new member IDs starting with the letter “K” followed by 10-digits (K-ID). We have found that some providers are still using the old member IDs on their electronic transactions (e.g., 270, 276, 837, etc.).

Now that we are beyond the timely filing deadline for all possible claims that the old member IDs could apply to, we decommissioned our old claims systems. We have also retired and can no longer accept or use the old Commercial and Medicare member IDs. This means that the K-ID must be used for these members, otherwise your:

• Claims will be denied.
• Eligibility and preauthorization transactions on our provider portal will show that the member cannot be found.
• Incorrect information will be returned on electronic transactions if  the member cannot be found.

We updated the Payment Integrity Policy for the Laboratory Benefit Management Program to add Coronavirus Testing in the Outpatient Setting (LBM) to the Reimbursement Policies table.

We are introducing two new reimbursement policies:

• Starting July 14, 2023, the Radiopharmaceuticals and Contrast Media policy will determine how EmblemHealth and ConnectiCare reimburse claims billed with radiotracers and/or contrast materials.
• To reflect the end of the COVID Public Health Emergency, we are replacing our previous COVID Testing Reimbursement Policy with this new one: Coronavirus Testing in the Outpatient Setting (LBM).

The following five reimbursement policies have been updated. See Revision History sections for changes and effective dates:

• Allergy Testing Immunotherapy Reimbursement Policy was updated to clarify that facility fees for allergy testing are limited to one unit per day (CPT Codes 95004, 95017, 95018, 95024, or 95027). This includes allergy testing for intradermal test, patch tests, and/or percutaneous scratch tests.
• Bundled Services (Commercial and Medicare) for EmblemHealth and ConnectiCare.
• Coding Edit Rules (EmblemHealth-Commercial | ConnectiCare-Commercial).
• Durable Medical Equipment (DME) in Office / Non-Facility Place of Service (Commercial and Medicare) for EmblemHealth and ConnectiCare.
• EmblemHealth’s Outpatient Imaging Self-Referral (Commercial) (Administered by eviCore Healthcare).

Lab/Venipuncture Reimbursement Policy
Consistent with CMS guidelines, EmblemHealth and ConnectiCare will only consider reimbursement for CPT Code 87631 (Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (e.g., adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets).

Starting July 14, 2023, EmblemHealth and ConnectiCare will not reimburse CPT Codes 87632-87633. Testing with five or more targets (pathogens) is considered not medically necessary. (EmblemHealth | ConnectiCare).

CPT and HCPCS Billing Guidelines
While EmblemHealth and ConnectiCare recognize some HCPCS codes, they are not always consistent with those recognized by Medicare. Exceptions may apply, such as Drug Testing. Unless otherwise specified, CPT codes should be billed when there is a corresponding HCPCS code.

Whenever possible, convert HCPCS Code(s) to the applicable CPT Code(s) before you submit your claims to EmblemHealth or ConnectiCare. When a more appropriate code is required, a service may be denied giving the provider an opportunity to submit a more appropriate code. See CPT and HCPCS Billing Guidelines.

Daily Maximum Units       
EmblemHealth and ConnectiCare follow CMS guidelines. We will not reimburse CPT/HCPCS codes with an Medically Unlikely Edits (MUE) value of “0” (zero). This applies to all EmblemHealth and ConnectiCare Medicare Advantage plans. For Medicare non-covered services that are covered by our Commercial plans, EmblemHealth and ConnectiCare have established maximum daily frequency (MDF) exceptions. These exceptions are listed in our Daily Maximum Units reimbursement policy.

We are committed to helping our members with diabetes. Managing this disease is complex. You can assist in simplifying medication regimes by reviewing and eliminating medicines with no added clinical benefit. 

The American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) recommend glucagon-like peptide 1 receptor antagonists (GLP-1) as an add-on therapy to oral agents and in combination with insulin for the treatment of diabetes.* Current guidelines by the ADA and AACE, as well as the Food & Drug Administration (FDA), do NOT support combination therapy of GLP-1 and Dipeptidyl peptidase 4 inhibitors (DPP-4) due to lack of added clinical benefit.

*All GLP-1 agonists (except Wegovy and Saxenda) are indicated only for type 2 diabetes.

See the full announcements (EmblemHealth | ConnectiCare) for recommendations for patients on a DPP-4 and GLP-1 and list of medications that have these medicinal components.

• The Orthognatic Surgery medical policies have been revised for both EmblemHealth and ConnectiCare to add:
  • Post-surgical improvement regarding speech impairments should be determined by a speech pathologist.
  • Maxillary cant and cross-bite malocclusion are examples of asymmetries.

Clarification that plaster, printed, or digital study models may be submitted as evidentiary documentation.

• The Glaucoma Surgery medical policies have been revised for both EmblemHealth and ConnectiCare to add the covered indication for One iStent infinite® Trabecular Micro-Bypass System Model iS3.
• ConnectiCare’s Medical Necessity Guidelines: Experimental, Investigational or Unproven Services (Commercial & Medicare) policy changes are shown in the Revision History Section.
• Predictive testing language was added to The Breast Cancer Index section of EmblemHealth’s Gene Expression Profiling and Biomarker Testing for Breast Cancer.
• The Infertility Services guidelines for EmblemHealth and ConnectiCare were revised as follows:
  
  
  • Section 3: Assisted Reproductive Technology (ART)
    • “Hysterosalpingogram (HSG), sonohysterosalpingogram, or hysteroscopic documentation of a normal endometrial cavity within the past two years” to in vitro fertilization section (for consistency with intrauterine insemination section).
    • Replaced “Diminished ovarian reserve (not due to age)” with “Premature ovarian failure”.
    
    
  • Section 5: Donor Services
    • Replaced “Clinically documented diminished premature ovarian reserve (as defined by American College of Obstetricians and Gynecologists)” with “Clinically documented premature ovarian failure (as defined by American College of Obstetricians and Gynecologists)”.


• The following medical policies have been retired:
  • EmblemHealth
    • Ambulatory Monitoring Electroencephalogram Genetic Analysis of PIK3CA Status in Tumor Cells
    • Genetic Testing for PTEN Hamartoma Tumor Syndrome
    • Non-Invasive Electroencephalogram
    • Therapeutic Shoes for Diabetics
  • ConnectiCare
    • Ambulatory Monitoring Electroencephalogram
    • Non-Invasive Electroencephalogram

The following guides were updated to show the new screens added to enhance the utilization review process:

• Create Emergent Inpatient Admission Notification
• Create Inpatient Preauthorization
• Create Outpatient Preauthorization

The following supplemental guides have been added to the provider portal training materials pages:

• Ambulance
• Home Health Care
• Private Duty Nursing

TIP: Do not skip the Submit Request button on the new screen. Using it may result in an immediate decision.

You can find these guides along with others, videos, and Frequently Asked Questions pages using the following links:

• EmblemHealth Videos and Guides
• EmblemHealth FAQs
• ConnectiCare Videos and Guides
• ConnectiCare FAQs

If you still have questions or need additional support, you may contact Provider Customer Service:

EmblemHealth: 866-447-9717

ConnectiCare: Commercial: 860-674-5850, Medicare: 877-224-8230

EmblemHealth works with Veradigm to offer free monthly webinars to help educate providers on best practices regarding the risk adjustment process, including accurate medical record documentation and claims coding to capture the complete health status of each patient.  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.

The Veradigm webinars are held on Tuesdays and Thursdays, one in the morning and one in the afternoon, to accommodate all schedules. Here are the June and July topics:

• June 27/29 - Incorporating Wellness…Evaluating Substance Use, Chronic Pain, and Behavioral Health
• July 25/27 - Feed Your Knowledge of the Most Common Gastrointestinal Disorders

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.

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, option 7, 8 a.m. to 8 p.m., Monday through Friday.

We recommend that you take advantage of the training opportunities offered by CMS’s Medicare Learning Network and eMedNY.