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Provider Toolkit

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Provider Resources

A dedicated page of useful materials you can give your EmblemHealth patients to help manage their care and keep their costs down.

 

Recently added

 

Welcome to EmblemHealth

Here is some information to help you get to know us and help you best serve our members, your patients.

  • Provider Portal Training Materials

  • 2023 Summary of Companies, Lines of Business, Networks - Updated 4/27/2023

  • 2023 Benefit Plans with No Referrals Required - Updated 2/10/2023

  • Medicaid/HARP/CHP Programs

  • Medicare Advantage Plans

  • Commercial Networks and Benefit Plans

  • Caring for Bridge Program Members

  • EmblemHealth Guide for Electronic Claims Submissions

  • Access and Availability Requirements

  • Network Laboratories – Quest Diagnostics and LabCorp are our preferred clinical laboratories

  • Frequently Asked Questions about Electronic Funds Transfer and Electronic Remittance Advice

  • Improving the Patient Experience

  • ConnectiCare Members May Use Providers in the EmblemHealth Prime Network

  • “How Do I…” Provider FAQs

  • ConnectiCare Website Information

 

Your Plan Members

 

Access to Care and Delivery System

  • Reminder: Keep Your Directory Data Current

  • How To Keep Your Directory Data Current

  • Network Laboratories – Quest Diagnostics and LabCorp are our preferred clinical laboratories

  • Quest Diagnostics

  • EmblemHealth Neighborhood Care Physician Referral Form

  • New York Medicaid Statewide Patient-Centered Medical Home Incentive Program

  • Compare Hospitals

  • Skilled Nursing Facility Quality Guide

  • New York State Nursing Home Profile

  • DME Preauthorization Request Checklist

  • Appointment Availability Standards During Office Hours & After Office Hours Access Standards

 

Medical Record Guidelines

  • CDC’s Recommended Immunization Schedules

  • HEDIS/QARR Medical Record Review and Clinical Data Collection

  • Medical Record Audits

  • Medical Record Review Tools

 

Claims

Visit Claims Corner for the latest information on our claims policies.

  • 29-I Health Facility Billing Guidance

  • 29-I Health Facility Billing Tool

  • Health Home Billing Guide

  • EPO/PPO Corrected Professional Paper Claim Form

  • National Provider Identifier (NPI) Reporting Sheet

  • Electronic Funds Transfer and Remittance Advice (EFT-ERA)

  • National Plan and Provider Enumeration System (NPPES)

  • Unlisted Procedure Codes Form

  • Assignment of Benefits Form

  • National Government Services Policy Education Topics: Modifier 25

 

Care Management

Visit Clinical Corner for practice guidance resources.

  • Foster Care AND 29-I Transmittal Form

  • Advise Your Patients to Visit Our Network Urgent Care Centers for Non-emergent Medical Care

  • Medical Policies

  • Medical Technologies Database

  • Care Management Programs

  • Occupational Health Clinic Joins EmblemHealth

  • NYCDOHMH Primary Care Information Project (PCIP): Public Health Action Kits for Providers

  • Information for Providers - Hepatitis C

 

Domestic Violence Resources

  • Domestic Abuse Guidelines

  • New York City Domestic Violence Resources

  • The Office for the Prevention of Domestic Violence

 

Health Promotion

 

Behavioral Health Services

  • Mental Health and Substance Abuse

    EmblemHealth strongly encourages care of the whole person. Please see screening tools and other valuable resources for the identification and treatment of mental health and substance abuse issues. 

  • Alcohol Abuse Screening Tool and Clinical Guidelines for Non-Mental Health Providers

  • Behavioral Health Screening Toolkit for Primary Care Physicians

  • Depression Screening Tool and Clinical Guidelines for Non-Mental Health Providers

 

Pharmacy Services

  • Visit Clinical Corner for formulary updates.

  • 2019 Medicare Part D Opioid Policies: Prescriber Tip Sheet

  • 2019 Medicare Part D Opioid Policies: Prescriber Webinar

  • EmblemHealth Medicaid Formulary

  • High Risk Medications for Elderly Patients

  • Medicare Requirement for Prescribing Part D Drugs

  • Non-FDA-Approved Drug Use and/or Dose Request Form

  • Physician Specialty Program Enrollment Form

  • Potentially Inappropriate Medication Use in Older Adults

  • Standing Orders for Influenza Vaccination and Other Vaccinations

  • Prescribing eHealth Initiative Best Practices and Guidance

  • ConnectiCare Pharmacy Services Prescription Drug Claim Form

 

EmblemHealth Spine Surgery and Pain Management Therapies Program

  • EmblemHealth Spine Surgery and Pain Management Therapies Program Guide

  • Pain Management Prior Authorization Request Form

  • Spinal Surgery Prior Authorization Request Form

 

Radiation Therapy, Cardiology Imaging and Radiology Programs

 

Physical and Occupational Therapy Program

 

Credentialing

See the Join Our Networks page and the Credentialing chapter of the EmblemHealth Provider Manual for our application instructions and credentialing and recredentialing policies, procedures and forms. 

 

Regulatory Mandatory Reporting

  • New York State Communicable Disease Reporting

 

Required Provisions To Network Provider Agreements

  • Assignment of Participating Provider Agreement to Health Insurance Plan of Greater New York (“HIP”)

  • Managed Care Law of 2009

  • Medicare Advantage Addendum

  • New York State Standard Clauses - April 2017

  • Special Provisions Related to Medicaid, CHIP and HARP Members

 

Additional Resources

  • Provider Checklist: Items Needed to Process Appeals

  • EmblemHealth HDHP Programs ConsumerDirect EPO and ConsumerDirect PPO

  • Home Incentive Program Practitioner Quick Reference

  • Legislation Enacted To Increase HIV Testing in New York State

  • Office of Health Insurance Programs Principles for Medically Fragile Children

  • Provider Quality Measure Resource Guide

 

Archive

  • Expired: 2022 Summary of Companies, Lines of Business, Networks and Benefits Plans

  • 2022 Benefit Plans That Do Not Require A Referral

  • Expired: 2021-2022 Annual Provider Notification

  • Expired: 2021 Summary of Companies, Lines of Business, Networks and Benefits Plans

    Updated 06/16/2021

  • Expired: 2021 Medicare Advantage Guide

  • Expired: 2021 Benefit Plans That Do Not Require A Referral

    Updated 04/15/2021

  • Expired: 2021 Quality Measure Resource Guide

  • Expired: 2021 Medicaid/HARP/CHP Resource Guide

  • Expired: 2021 Summary of Companies, Networks & Benefit Plans

  • Expired: 2021 Benefit Plans that Do Not Require a Referral

  • Expired: 2021 Helping Outreach to Individuals Eligible for Health and Recovery Plans and Behavioral Health (BH) Home and Community Based Services

  • Expired: 2020 Medicare Advantage Guide

  • Expired: 2019 Network and Benefit Plan Updates

  • Expired: 2018 Annual Plan News & Regulatory Reminders

  • Expired: 2019 EmblemHealth Benefit Plans with No Referrals Required

ALSO OF INTEREST

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© 2023 EmblemHealth. All Rights Reserved.

Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.