Office Visit

To make it easier for you to send us documents using the provider portal, we increased the file size for uploading supporting documentation for all transactions. You can now upload 25 MB per file. Here are some transactions you can use to send us documents:

• Appeals (for adverse medical determinations).
• Care Plans.
• Claim Inquiries.
• Grievances (for claim denials that do not involve a medical necessity determination).
• Notifications – admissions from the emergency room and for newborns.
• Preauthorizations, Concurrent Reviews,* and Discharge Plans.
• Provider Profile Changes.

We encourage you to use the provider portal instead of mailing or faxing us documents so you can get your answer faster.

*For Concurrent Reviews: Attach documents to the original preauthorization request or case created by notification of admission from the emergency room (including maternity admissions).

EmblemHealth is committed to serving our partners at the City of New York, as well as delivering access to quality, affordable care to city employees, retirees, and their dependents. To facilitate this, we want to make you aware of the following information, including important notices and changes going into effect soon:

Do Not Collect Copays for Senior Care Members

EmblemHealth has suspended the $15 copay for City of New York retirees receiving certain services offered through the GHI Senior Care Plan. You should NOT collect this copay when providing the following services:

• Office visits (primary care providers, or PCPs).
• Office visits (specialists).
• Urgent care.
• Allergy testing/injections.
• Chiropractic services.
• Podiatry (non-routine).
• Cardiac rehab.
• Pulmonary rehab.
• Vision care (Medicare-covered).
• Physical therapy, occupational therapy, and speech therapy.
• Diagnostic lab/x-ray (including Hi Tech Imaging).
• Radiation therapy.
• Outpatient – mental health.
• Outpatient – substance use disorder.

For more information, visit our City of NY Page.

Changes to CBP Plan Copays

CNY members with GHI Comprehensive Benefits Plan (CBP) benefits will see the following changes:

• Effective April 1, 2023, CityMD Urgent Care centers will have a $100 copay. This is in addition to the ProHEALTH change for CNY members announced in the October 2022 Provider Newsletter. 
• Effective April 1, 2023, Zwanger-Pesiri Radiology Group’s high-tech radiology imaging procedures (including, but not limited to: 3DI, CT scan, MRA, MRI, Nuclear Medicine, and PET scan) will have a $50 copay. This is an update to CNY PPO High-Tech Radiology tiering ($50.00 for a preferred facility and $100.00) first announced in the October 2022 Provider Newsletter. Refer to our regularly updated Summary of Companies, Networks, Benefits, and Plans document for complete details on this and other benefits.
• Effective Oct. 1, 2022, all Montefiore providers have a $15 primary care provider (PCP) copay or a $30 specialist copay, like all other non-preferred providers.

Changes to Preferred PCPs in the HMO Preferred Plan

As of April 1, 2023, we will make changes to the preferred PCPs in the Prime Network for the HMO Preferred Plan. Here is what is changing:

• $0 copay for services with a SOMOS PCP. If a member has a SOMOS PCP, there will be a $0 copay for most services, including in-network specialist visits.
• $10 copay for services with a Montefiore PCP. Montefiore PCPs will be non-preferred providers after April 1, 2023. If a member has a Montefiore PCP, there will be a $10 copay for most services.

Be sure to consult our Summary of Companies, Networks, Benefits, and Plans document on the Provider Toolkit. It contains information on copays and more for all EmblemHealth and ConnectiCare networks and plans.

We are pleased to announce that ConnectiCare reached an agreement with Prospect Medical Holdings. This means Prospect Medical’s hospitals and associated providers will remain in the ConnectiCare network without a lapse in participation. Our members may continue to get in-network, covered care with their doctors and at the following hospitals:

• Prospect Waterbury Hospital.
• Prospect Manchester Memorial Hospital.
• Prospect Rockville General Hospital.
• Prospect Provider Group Connecticut (Prospect Professional Provider IPA).

We thank our providers for their continued care of our members. 

EmblemHealth’s risk adjustment program is designed to help our primary care providers (PCPs) identify members with chronic conditions who require an annual evaluation. The program also supports correct coding and documentation of the severity of the member’s condition.

We work with Veradigm (previously known as Pulse8) to capture the complete health status of each New York State of Health (NYSOH) Marketplace, Medicare HMO, and Medicaid member. We look to our PCPs to maintain accurate medical record documentation and claims coding and provide evidence of ongoing care to support accurate reimbursement from government programs.

As a bonus, PCPs who also complete a compliant provider alert and provide the supportive progress note(s) in Veradigm’s Collaborate Provider Portal can receive additional reimbursement.

The 2023 EmblemHealth Risk Adjustment Program for Primary Care Providers (PCPs) runs from Jan. 1, 2023, through Dec. 31, 2023.

Veradigm offers a series of free, 60-minute monthly webinars. Each session is followed by a question-and-answer period. You may register for the monthly webinars through the secure provider portal or on our website’s Learning Online Veradigm Webinar page.

The 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 upcoming topics:

• March 28 and 30: The Ultimate Guide to Documentation and Coding.
• 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.

We encourage you and your staff to take advantage of this educational opportunity.

2023 Collaborate Provider Portal

PCPs can visit Veradigm’s Collaborate Provider Portal via the EmblemHealth provider portal. Collaborate is a web-based tool that supports improvements in documentation, quality, and risk score accuracy.

If you are interested in learning more about how you can view Veradigm’s provider resources and webinars, contact Veradigm’s Customer Support team Monday through Friday, 8 a.m. to 8 p.m., at 800-877-5678, option seven. Or, send an email to support@veradigm.com.

*You can also see our own medical director’s perspective on population health and the social determinants of health.