Office Visit

Starting Jan. 1, 2026, network providers will see some operational changes in how to work with ConnectiCare to serve our Marketplace and Medicare members. Details about these important changes and other key resources are available on our provider hub.

Attend these provider orientation and training webinars to understand how these changes will impact your practice.

• ConnectiCare will host Provider Orientation webinars on the following dates to review operational changes in detail. Select one of the dates below to join the meeting:
  • Monday, Dec. 8, from 10 to 11:30 a.m.
  • Wednesday, Dec. 10, from 2 to 3:30 p.m.
  • Monday, Dec. 15, from 10 to 11:30 a.m.
  • Wednesday, Dec. 17, from 2 to 3:30 p.m.
• Providers will use the Availity Essentials portal to perform various functions online with ConnectiCare, including submitting claims and prior authorization requests. Starting in December 2025, Availity will email you directly from reply@ discover.availity.com with instructions on how to Get Started with Availity Essentials, watch recorded training demos, and register for upcoming live webinar trainings:
  • Monday, Jan. 5, from noon to 1 p.m. (claims)
  • Wednesday, Jan. 7, from 2 to 2:45 p.m. (authorizations)
  • Monday, Jan. 12, from 2 to 2:45 p.m. (authorizations REPEATED)
  • Tuesday, Jan. 13, from 10 to 11 a.m. (claims REPEATED)
• Evolent will conduct medical necessity reviews for medical and radiation oncology for adult members aged 18 and older. To help you prepare, Evolent will host live webinar training sessions on how to use the Evolent provider portal to submit prior authorization requests. Register for one of the upcoming sessions:
  • Tuesday, Dec. 9, from 9 to 10 a.m.
  • Thursday, Dec. 11, from 1 to 2 p.m.
  • Tuesday, Dec. 16, from 9 to 10 a.m.
  • Thursday, Dec. 18, from 1 to 2 p.m.

IMPORTANT NOTE: These sessions do not apply to business practices for ConnectiCare commercial members with an ID number that starts with “K”. For these members, providers will continue to follow ConnectiCare’s current policies and procedures through the end of 2026.

ConnectiCare has selected Prime Therapeutics™ (Prime) to manage medical pharmacy drug benefits and pharmacy benefits for our commercial plan members starting Jan. 1, 2026. To request prior authorization for medical pharmacy, contact Prime directly by phone at 833-519-4548 or online at GatewayPA.com. For pharmacy benefit management prior authorization requests, use the electronic prior authorization system through CoverMyMeds^® or call Prime at 866-799-7919.

To help you prepare for this change, Prime will host a live webinar training session on Friday, Dec. 12, from noon to 1 p.m. RSVP to attend.

IMPORTANT NOTE: This change only applies to commercial members with an ID number that begins with “

ConnectiCare will observe the 38^th annual World AIDS Day on Dec. 1, through our commitment to prevent new HIV infections and provide essential services to our members.

In support of this effort, we offer a Care Management program to help our members living with HIV/AIDS. To refer a member to the program, call 800-390-3522 from 8 a.m. to 4 p.m., Monday, Thursday, and Friday, or from 8 a.m. to 7:30 p.m., Tuesday and Wednesday.

Here are some other resources you can use and share with members.

• HIV/AIDS Services in Connecticut: core medical and supportive services to people living with HIV or AIDS (PLWHA) and their families from the State of Connecticut Department of Public Health.

• CDC HIV PrEP Resources: an online library of HIV resources, including HIV PrEP, which is a pre-exposure prophylaxis (PrEP). It may protect patients against HIV even if their partner has HIV.

Our 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 events.

Let your patients know that the Red Cross Blood Drive will be held on Monday, Dec. 1, from 10 a.m. to 3 p.m. at the ConnectiCare Center in Manchester. Registration is required; walk-ins are also welcome.

Observe Pulmonary Hypertension Month in November by discussing with members how self-monitoring at home may help lower their blood pressure. They can report their blood pressure verbally during a telehealth (telephone, e-visit, virtual) or office visit.

This is a HEDIS^® measure. This initiative can also help support your blood pressure data capture and the management of your patients, and improve your performance rate for the Quality measure: Controlling Blood Pressure.

Here are recommended steps you can take to help members with hypertension:

• Encourage patients to monitor their blood pressure at home using a digital at-home device.
• Clearly document in the Medical Record that the reading was taken by a digital device and the date it was taken. Blood pressure readings taken by a patient using a non-digital device (e.g., manual blood pressure, stethoscope) do not meet criteria. Electronic submission from the device is not required, though it is recommended.

For more information on self-monitoring tools and protocols, the CDC has educational materials for members to support Self-Measured Blood Pressure Monitoring | Million Hearts^® (hhs.gov)

 Medicare Advantage Telehealth Reimbursement

EmblemHealth will continue to pay Medicare Advantage telehealth as usual during the government shutdown. We have not made any changes to what or how we pay Medicare Advantage telehealth at this time.

See Medicare Networks and Benefit Plans for our 2026 offerings.

 Do Not Bill Members With Full Medicaid or QMB 

If Medicare-Medicaid dual-eligible individuals have their Part A and Part B cost share fully covered by their Medicaid plan or are Qualified Medicare Beneficiaries (QMBs), they are not responsible for their Medicare Advantage cost share for covered services. Please do not balance bill these members for any other costs. Any Medicare and Medicaid payments for services given to these members must be accepted as payment in full.

For ConnectiCare members, visit the Connecticut Department of Social Services or call 800-842-8440. For more details, see ConnectiCare Medicare Advantage Plans.

For EmblemHealth members, use ePACES to check whether the member has full or partial Medicaid benefits. For more details, see Medicare Advantage Plans.

See Commercial Networks and Benefit Plans for our 2026 offerings.

See Marketplace Networks and Benefit Plans for our 2026 offerings.

EmblemHealth and ConnectiCare are adding one new Lab Benefit Management (LBM) Reimbursement Policy: Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases (LBM).

The following reimbursement policies have been updated. If the policy name does not have a company name shown, the policy applies to both EmblemHealth and ConnectiCare. See their revision histories for effective dates and applicable changes:

• Ambulatory Surgical Groupers.
• Beta-Hemolytic Streptococcus Testing (LBM).
• Biochemical Markers of Alzheimer Disease and Dementia (LBM).
• Bone Turnover Markers Testing (LBM).
• Bundled Services.
• Celiac Disease Testing (LBM).
• Cervical Cancer Screening (LBM).
• Diabetes Mellitus Testing (LBM).
• Diagnosis of Vaginitis (LBM).
• Diagnostic Testing of Common Sexually Transmitted Infections (LBM).
• Diagnostic Testing of Influenza (LBM).
• DME Rental vs. Purchase.
• Epithelial Cell Cytology in Breast Cancer Risk Assessment (LBM).
• Evaluation and Management (E&M) Services.
• Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing (LBM).
• Fecal Calprotectin Testing in Adults No CPT code changes (LBM).
• Gamma-glutamyl Transferase Testing in Adults (LBM).
• Human Immunodeficiency Virus (HIV) (LBM).
• Immunopharmacologic Monitoring of Therapeutic Serum Antibodies (LBM).
• In Vitro Chemoresistance and Chemosensitivity Assays (LBM).
• Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease (LBM).
• Laboratory/Venipuncture.
• Metabolite Markers of Thiopurines Testing (LBM).
• Oral Cancer Screening and Testing (LBM).
• Pathogen Panel Testing (LBM).
• Prenatal Screening (Nongenetic) (LBM).
• Preventive Care Services (Commercial).
• Preventive Care Services (Medicare).
• Prostate Biopsy Specimen Analysis (LBM).
• Radiopharmaceuticals and Contrast Media.
• Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease (LBM).
• Testing for Alpha-1 Antitrypsin Deficiency (LBM).
• Testing for Diagnosis of Active or Latent Tuberculosis (LBM).
• Testing for Vector-Borne Infections (LBM).
• Urine Culture Testing for Bacteria (LBM).

EmblemHealth and ConnectiCare update their claims processing systems based on code updates received from American Medical Association (AMA), CPT, and Centers for Medicare & Medicaid Services (CMS). Both the AMA and CMS release quarterly updates to their respective code sets. Below are links to the latest preauthorization lists.

We strive to load and configure each code update within 60 days of the update’s effective date. The current process will hold the entire claim if it contains a new code while it is being configured. To avoid delaying critical payments to our providers, we adjudicate the claim for all services except for the new code(s) that need configuration. Once the new CPT and/or HCPCS codes have been loaded into our claims processing system, we will reprocess the claims to ensure proper adjudication of the claim.

The following medical policies were updated. See Revision Histories for applicable updates and effective dates:

• ConnectiCare: Experimental Investigational or Unproved Services Policy.
• ConnectiCare’s Bariatric Surgery medical guideline has been updated to add:
  • Language for members of Asian descent with a body mass index (BMI) of ≥ 37.5 kg/m2.  
  • Idiopathic intracranial hypertension (pseudotumor cerebri) and evidence of nonalcoholic fatty liver disease (NAFLD) to primary disease complication list.
• EmblemHealth Revised Medical Policies:
  • Medical Necessity Guidelines: Experimental, Investigational or Unproven Services.
  • Bariatric Surgery.
  • Cortical Stimulation for Epilepsy (NeuroPace^®).

The following medical policies are being retired from the EmblemHealth website. Starting Oct. 27, 2025, these services will be managed by EviCore:

• Automatic External Defibrillators.
• Continuous Passive Motion Devices.
• External Breast Prosthesis/Bra.
• High-Frequency Chest Wall Oscillation Devices and Intrapulmonary Percussive Ventilators.
• Mechanical Stretching Devices.
• Orthopedic Footwear.
• Vacuum-Assisted Wound Closure.

If you need help navigating our provider portals, please see our videos, quick guides, and Frequently Asked Questions pages:

• ConnectiCare Videos and Guides.
• ConnectiCare Frequently Asked Questions.
• EmblemHealth Videos and Guides.
• EmblemHealth Frequently Asked Questions.

If you still have questions or need additional support, contact Provider Customer Service using the provider portal’s Message Center or live agent chat.

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

If a provider in your practice is leaving, please inform us as soon as possible. See how to submit data changes as required by our participation agreements for ConnectiCare and EmblemHealth.

If you participate with us under a delegated credentialing agreement, please have your administrator submit these changes.

Remember to review your CAQH application every 120 days and ensure you have authorized us as an eligible plan to view your CAQH information.