Office Visit

We recently published the 2026 Summary of Companies, Lines of Business, Networks, and Benefit Plans. This chart shows the plans we will offer in 2026 and makes it easy to see which plans are part of a network or line of business covered by your ConnectiCare contract.

In November, you will be able to review the anticipated changes to our networks, benefit plans, and policies for 2026, by visiting: 

• ConnectiCare Commercial Networks and Benefit Plans.
• ConnectiCare Marketplace Networks and Benefit Plans.
• ConnectiCare Medicare Networks and Benefit Plans.

Marketplace and Medicare Plans

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

Below are some changes regarding prior authorization requests. Training on these new procedures will be provided in December 2025. Dates and times will be announced in the next Office Visit provider newsletter.

• ConnectiCare will adopt Molina’s Marketplace and Medicare Prior Authorization List for services that require prior authorization. To find the prior authorization requirements for specific codes, use the Prior Authorization LookUp Tool.
• Providers will use the Availity Essentials portal to perform various functions online with ConnectiCare, including submitting prior authorization requests. 
• ProgenyHealth will perform NICU utilization and care management services for our Marketplace members. Providers can contact ProgenyHealth directly to request prior authorization for these services by phone at 888-832-2006 or by fax at 877-847-1708.
• Evolent will conduct medical necessity reviews for adult members aged 18 and older for medical and radiation oncology. Refer to Evolent’s prior authorization lists for Radiation Services, Medication Oncology, and Diagnosis Codes. Providers can contact Evolent directly to request prior authorization for these services by phone at 888-999-7713 (select option 2 for medical oncology, option 3 for radiation oncology) or online at my.newcenturyhealth.com.

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

Commercials Plans

Starting Jan. 1, 2026, eviCore will no longer perform genetic testing utilization management for ConnectiCare commercial members. Instead, network providers can submit prior authorization requests for genetic testing directly to ConnectiCare via the provider portal. Approvals issued before Jan. 1, 2026, will remain valid until the authorization end date.

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

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 about these upcoming events at the ConnectiCare Center in Manchester:

• Force Fitness will offer a nutrition program on Thursday, Oct. 16, from 6 to 8 p.m. Registration is required.
• More Fire Fitness will offer a children’s event on Saturday, Oct. 25, from 10 a.m. to noon, featuring an animal-themed exercise class, face painting, balloon animals, and more. Registration is required.
• More Fire Fitness will offer a four-week exercise class (More Fire FITE) on Wednesday, Oct. 29  at 5:30 p.m. The class is open to ConnectiCare members only. Registration is required.
• Community Café Conversation Series: Families & Prevention class for parents and families will be held on Thursday, Nov. 6, from 5 to 7 p.m. Vaping, Highs, and Hazards: What Every Parent Should Know is the third in a three-part series that will evaluate the risks of vaping and other common substances and apply prevention strategies to support youth. Registration is required.
• Red Cross Blood Drive will be held on Monday, Dec. 1, from 10 a.m. to 3 p.m. Registration is required, and walk-ins are welcome.

The American Diabetes Association has provided recommendations to help people living with diabetes manage their condition and improve their health. Here are some recommended preventive screenings for your patients with diabetes:

• Regular A1c testing.
• Kidney function testing.
• Ankle-brachial index.
• Annual retinal eye exam.
• Cholesterol and triglycerides testing.
• Blood pressure testing.

Please visit Health Checks for People with Diabetes | ADA for more information and resources.

Information is also available to assist with coding guidance for closing the Quality gap in care. Please visit our Quality Improvement website and download the Quality Measure Resource Guide for more information.

Ten years have passed since the U.S. Preventive Services Task Force (USPSTF) first recommended low-dose CT for lung cancer screening, yet lung cancer screening rates remain low, with less than 1 in 10 eligible individuals having undergone CT screening.

November is a good time to encourage your patients to get screened for lung cancer. The American Cancer Society and USPSTF recommend yearly lung cancer screening with a low-dose CT scan for current and former heavy smokers ages 50 and older.

Find valuable resources sponsored by the American Cancer Society to support your patients’ screening here:

National Lung Cancer Roundtable

Lung.org

Starting Jan. 1, 2026, ConnectiCare and EmblemHealth are introducing Nutritional Counseling Services Reimbursement Policies. Refer to the website applicable to the member’s plan (ConnectiCare | EmblemHealth) to see the relevant policy.

The following reimbursement policies have been updated for both ConnectiCare and EmblemHealth. Refer to the website applicable to the member’s plan (ConnectiCare | EmblemHealth) and see the revision histories for effective dates and applicable changes.

ConnectiCare

• ConnectiCare DME Rental vs. Purchase Reimbursement Policy
• ConnectiCare Free Flap Breast Reconstruction
• ConnectiCare Procedure/Surgery Performed in Physician’s Office (Facility & Equipment), formerly known as Modifier SU – Procedure Performed in Physician’s Office (Commercial)
• ConnectiCare Preventive Care Services (Commercial) Reimbursement Policy
• ConnectiCare Preventive Care Services (Medicare) Reimbursement Policy

   

  EmblemHealth

• EmblemHealth DME Rental vs. Purchase Reimbursement Policy
• EmblemHealth Free Flap Breast Reconstruction
• EmblemHealth Procedure/Surgery Performed in Physician’s Office (Facility & Equipment), formerly known as Modifier SU – Procedure Performed in Physician’s Office (Commercial)
• EmblemHealth Preventive Care Services (Commercial and Medicaid) Reimbursement Policy
• EmblemHealth Preventive Care Services (Medicare) Reimbursement Policy

Please remember that ConnectiCare and EmblemHealth do not accept most HCPCS codes on claims for medical, surgical, and/or diagnostic procedures for our commercial and Medicaid plans. Instead, providers should submit claims with the appropriate CPT code(s) that accurately identify the procedure(s) and/or service(s) performed.

Free Flap Breast Reconstruction

ConnectiCare and EmblemHealth require providers to submit CPT code 19364 to report breast reconstruction via a free flap. We do not accept HCPCS Level II S2066-S2068. To help with proper coding, we have updated our reimbursement policy to include a clarifying example regarding Free Flap Breast Reconstruction (HCPCS codes S2066-S2068).

The history behind the codes explains why we need our providers to use CPT code 19364. At a time when there was no national code to adequately describe free flap breast reconstruction, the Blue Cross/Blue Shield association developed the temporary HCPCS Level II codes S2066-S2068. Since the development of the temporary “S” codes, the AMA updated CPT code 19364 to describe free flap breast reconstruction via the techniques described in S2066-S2068 (GAP, DIEP, and SIEA flaps). Therefore, ConnectiCare and EmblemHealth do not accept HCPCS Level II S2066-S2068 to report breast reconstruction via a free flap and require providers to submit CPT code 19364 instead.

The following medical policies are being updated. Changes and effective dates are shown in their respective Revision Histories.

• ConnectiCare: Medical Necessity Guidelines: Experimental, Investigational or Unproven Services (Commercial & Medicare)
• EmblemHealth: Medical Necessity Guidelines: Experimental, Investigational or Unproven Services

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.