eNewsFlash for Providers

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Important Reminders for 2017


Avoid Delays for You and Your Patients


Be sure to check the back of the member ID card to help you find who to ask for approval for services and where to submit claims.


Review 2017 Medicare Benefit and Plan Changes


Hospitals Must Use the Medicare Outpatient Observation Notice

Starting on March 8, 2017, all hospitals must give written and oral notice to anyone getting observation services as an outpatient for more than 24 hours. The form, Medicare Outpatient Observation Notice (MOON), includes the reason and effects of receiving outpatient services. This is required by the federal Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act.


Tips for Better Patient Communication

  • Be an active listener.
  • Use language that is easy to understand.
  • Use our Language Line. Call 1-866-447-9717 to find a translator.
  • Involve patients in decision making.
  • Practice cultural sensitivity.
  • End the visit with "Do you have any questions?"

Update to City of New York HMO/PPO PBA Member Benefits

The Tiered Benefit Product is now available to members of the Patrolmen's Benevolent Association (PBA). This benefit offers lower costs for members who choose preferred in-network doctors. Members will pay higher copays if they visit non-preferred providers. New ID cards have been sent to affected members. See our Policy Alert for all plan benefits.

Pharmacy Updates


Target and CVS Pharmacies Are No Longer In Network for Medicaid and HARP Members

Use the Pharmacy Locator to find in-network choices.

Medicare Patients Pay Less When you Choose Lower Tier Formulary Drugs

To help patients save money, consider prescribing lower cost alternatives listed on our full Formulary list. It’s a good idea to check our site monthly for updates to the list.


Claims Corner


EmblemHealth Adopts Changes to American Medical Association CPT Coding Guidelines

On January 1, 2017, changes were made to the Current Procedural Technology (CPT) coding guidelines for the list below. Click on the links to learn what these changes are.

  • Drug Testing and Screening
    There are changes to the Centers for Medicare & Medicaid Services’ (CMS’) drug testing and screening codes listed below.
    • 2015 AMA CPT Drug Testing Codes (80300 – 80377)
    • 2016 CMS Drug Testing Codes (G0477 – G0483)
    • Physician Point-of-Care Drug Screening
    • 2017 CMS Drug Testing Codes

EmblemHealth Changes Pain Management Rule for Trigger Point Injections

Starting on March 1, 2017, claims for any combination of trigger point injections will be denied if:

  • billed more than three times in a 90-day period.
  • for the same anatomic site.
  • given without medical necessity.

When a given site is injected, it will be considered one service, no matter how many injections are given.


Helping Patients

Support Medicaid Recertification

Remind Medicaid members to recertify before their Eligibility End Date. If members do not recertify on time, they will lose coverage and be forced to reapply. Here’s how to determine end dates.

Tell Us What You Think

You may have recently received our Physician Satisfaction Survey by mail and fax. Please take a few minutes to fill out this brief survey. Your input is vital because we want to make it easier for you to work with us.

Use Quest Diagnostics

Quest is our preferred, free-standing, independent commercial lab for members. Please direct our members to the nearest Quest Laboratory Patient Service Center. If you need to set up an account with Quest, please call 1-866-697-8378.

For specialty lab tests not available from Quest, you may use one of the other contracted, free-standing, independent commercial labs or contracted hospital labs.

Tips to Improve Your Patients' Experiences

Follow Access and Availability Standards

Learning Opportunities

New Medication Coverage Rules for City of New York PPO Members

Monthly Trainer-Led Webinars

Come learn about our networks, benefit plans, web-based tools and resources. These are offered the second Wednesday of each month, at 10 am or 2 pm.

Our next webinar is scheduled for Wednesday, March 8, 2017

Space is limited, Register today.

Take a Tour and Learn How to Use our Secure Provider Portal

After login, health care professionals can check eligibility and get an up-to-date member Panel Report, listed under My Reports. To learn more, Take a Tour today.

Keep Your Directory Information Current

Know Your Network Participation

Your provider profile lists your network affiliations. To view it, please log in to your Provider/Practice Profile on our secure provider portal at emblemhealth.com. If your network affiliation matches the network on the member's ID card, then you are in-network for that member's benefit plan. See the Provider Networks and Member Benefit Plans chapter of the EmblemHealth Provider Manual for a listing of all networks and plans.



Policy Alerts


Commercial Coordination of Benefits 837D Electronic Claims Transactions

Did you know EmblemHealth accepts electronic dental claims for payment as a secondary insurance carrier? Learn more about the benefits of electronic claims.

EmblemHealth Vision Services Program

EmblemHealth now uses EyeMed Vision Care IPA, LLC (EyeMed) for all member vision benefits.


Other News & Updates


Help your Patients Quit Smoking

We partner with the New York State Smokers Quitline to get our members to quit smoking. If you have patients ready to quit, urge them to call the New York State Quitline at 1-866-NY-QUITS (1-866-697-8487), or 1-877-500-2393 for non-NY residents. Add the five As of assessment to all your visits and get paid for patient counseling.

Help your Patients Quit Smoking

EmblemHealth Partners with DentaQuest

DentaQuest now manages the dental benefits for members in the these networks:

  • VIP Prime
  • Medicare Essential
  • Enhanced Care Prime
  • Prime
  • Premium (aka Vytra Premium)
  • Select Care

It includes use of out-of-area benefits (via Careington) through our Preferred/Plus Dental Network. Go to dentaquest.com for more details, or call them at 1-844-822-8108, Monday to Friday from 8 am to 5 pm.


Medical Policies


The Medical Policies page has a large list of medical technologies reviewed by the Medical Policy Subcommittee for coverage consideration. Below is a list of policies that have changed.



Help Your Patients’ Compliance - Improve Your Cultural Competency

Make sure your patients know what they need to do after an office visit. If they don't understand what they have to do, they can't comply. If language is a barrier, use the EmblemHealth Language Line for:

  • Free multi-language interpreters. Call 1-866-447-9717.
  • Sign language interpreters that are available for office visits. Providers or members may call the Customer Service Department at 1-646-447-6534, or LanguageLine Solutions at 1-800-874-9426.
  • TTY/TDD users, dial 711.

Remember to update your EmblemHealth Provider Profile to include your spoken languages. It will help our non-English speaking members find you.


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Coverage underwritten by Group Health Incorporated (GHI) and HIP Health Plan of New York (HIP).
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