Billing Prenatal and Postpartum Visits for Medicaid Members
CLINICAL CORNER
Preauthorization Updates
OrthoNet Portal Redirect Starting April 30
PHARMACY
New Specialty Pharmacy Reimbursement Policy
Pharmacy Preauthorizations
MEDICAL POLICIES
Medical Policy Updates
TRAINING OPPORTUNITIES
Provider Portal Videos and Guides
Free Patient Management and ICD-10 Coding Webinars
Valuable Training Available
IN EVERY ISSUE
EmblemHealth Neighborhood Care and ConnectiCare Centers
Keep Your Directory and Other Information Current
Consult EmblemHealth’s Online Provider Manual for Important Information
Feature Stories
GHI and HIP are part of EmblemHealth
EmblemHealth is a company built on decades of tradition, serving our members and the communities in which they live. Along the way, we have had many names—and understanding our current company names can help avoid confusion and allow you to see more members.
It is important for your practice to understand and be familiar with our most current EmblemHealth company names:
Group Health Incorporated (GHI) (now known as EmblemHealth Plan, Inc.),
Health Insurance Plan of Greater New York (HIP), and
Health Insurance Company of New York (now known as EmblemHealth Insurance Company).
Remind your appointment schedulers and insurance verifiers to use the Check Provider Network Status look-up tool in the Provider Portal under the Member Management menu to see if you are a participating provider for a patient.
When a member calls for an appointment and says their insurance is EmblemHealth, they should not be denied an appointment because your original provider agreement says HIP or GHI. Take care to verify their eligibility and, if their benefit plan is one you can accept, welcome them into your practice.
New Provider Portal Enhancements
New: Accumulators
We have added accumulators on the member Benefits and Eligibility Details page to show you how many claims we have received against certain benefits that may have limits. This will help you understand whether services you plan to provide will be paid for by our plan or whether you need to arrange payment with your patient.
New: Specialized Area
To submit updates to your NCQA-recognized Specialized Areas, please use the Ask a Question button located on the Provider Profile page in our provider portal. Specialized Areas is not a data element captured in the CAQH application. That is why you need to use our portal to communicate this information to us. Most changes should be submitted using CAQH. See Keep Your Directory Information Current for exceptions.
The following EmblemHealth Quality program materials have been updated and are available on the EmblemHealth provider website. Click below to view helpful information.
The Quality Incentive Programoffers incentives to primary care providers at the group level for improving the quality of care for members. This program aims to improve access to essential care services, and support providers in delivering exceptional health outcomes.
The Maternity Quality Incentive Programoffers incentives to OB/GYN providers for improving the quality of care for members during their pregnancy and postpartum period. This program aims to improve access to essential care services and support providers in delivering exceptional maternal health outcomes.
The Quality Measure Resource Guideprovides details of quality measures, descriptions of documentation/coding, best practices, and steps to close care gaps. This guide will help you satisfy national and state quality measures that evaluate preventive, acute, and chronic care.
Our Member Rewards Programs can be used as a tool to engage with patients and encourage their regular visits, helping you boost patient retention and ensure consistent care. The programs are open to all EmblemHealth Medicare Advantage plan members, including those in a dual-eligible special needs plan (DSNP); Enhanced Care (Medicaid), Enhanced Care Plus (HARP), and Child Health Plus (CHPlus); and Essential Plan members.
May is Mental Health Awareness Month
In recognition of Mental Health Awareness Month, which is observed in May, we want to highlight the importance of medical care providers coordinating care of patients with mental health and substance use disorders.
When providing care, be sure to look out for signs of mental illness and refer members for behavioral health services, if needed.
We are here to help you understand and address their health care needs. Please review the resources below to help support mental health awareness:
Providers can help address and coordinate behavioral health care by:
Screening for mental health conditions.
Talking about the medications patients take so they can avoid potential harmful reactions.
Encouraging and coordinating 7-day follow-up care after mental health-related emergency department/inpatient admissions.
Helping connect members with a behavioral health specialist, if needed.
We are here to help.
EmblemHealth Members: For questions or help finding a behavioral health professional, please call Carelon at 888-447-2526. A representative can help 24/7. EmblemHealth members can stop by any of our Neighborhood Care locations for community support. Visit emblemhealth.com/neighborhood.
Women’s Health Week Is May 11-17
National Women’s Health Week begins on Mother’s Day each year to encourage women and girls to make their health a priority.
Women represent the cornerstone of a family's overall health. Ensuring they have access to quality care can also lead to improved health for children and families.
According to the Centers for Disease Control and Prevention (CDC), two out of every three caregivers in the United States are women. This means they provide daily or regular support to children, adults, or people with chronic illnesses or disabilities. Women who are caregivers have a greater risk for poor physical and mental health.
For tips on what you can do to support your female patients please visit our website.
The CDC also offers tips on what you can do to support your female patients.
Medicare Updates
Medicare Outpatient Observation Notice (MOON)
The Centers for Medicare & Medicaid Services (CMS) requires all hospitals and critical access hospitals to provide Medicare beneficiaries, including Medicare Advantage enrollees, with the Office of Management and Budget approved Medicare Outpatient Observation Notice (MOON). Visit CMS for details on MOON and instructions for completing notices.
Claims Corner
Reimbursement Policies
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:
Billing Prenatal and Postpartum Visits for Medicaid Members
As announced in November 2024, claims using global bill codes for prenatal and postpartum services provided to New York state Medicaid members must have a Category II CPT code in addition to the global code starting April 15, 2025.
The following Category II CPT Codes must be included on a claim: 0500F (Initial Prenatal Visit), 0502F (Subsequent Prenatal Visit), or 0503F (Postpartum visit) for each corresponding visit provided to the patient within the obstetric global period being billed. Claims submitted without the appropriate Category II CPT codes will be denied. For details, see EmblemHealth’s Coding Edits Reimbursement Policy.
Starting April 30, 2025, providers seeking preauthorizations from OrthoNet will be redirected from OrthoNet’s portal to the One Healthcare ID registration page. If you already have a One Healthcare ID account, you will be able to sign in to the portal using your current credentials. If you do not have log in credentials, please register for an account here.
Preauthorizations submitted before and after April 30, 2025, will be available on the existing OrthoNet portal. Providers will continue using the OrthoNet portal using your One Healthcare ID login credentials.
If you need your provider ID or password for the Optum website, or if you have questions, please contact Optum Health Services at 844-730-8503.
Effective July 14, 2025, EmblemHealth participating outpatient providers — outpatient hospitals, physician offices, member homes, and ambulatory infusion centers — will be required to obtain certain drugs from specific specialty pharmacies.
The specialty pharmacy will bill EmblemHealth directly for the drug under the member's medical benefit. Outpatient providers may only seek reimbursement for administering the medication. Additionally, outpatient providers may not bill the member for the medication. The Specialty Pharmacy Requirements Drug List Policy excludes Home Infusion providers. The policy lists the applicable drugs and pharmacies you will need to use. Thispolicy does not apply to ConnectiCare.
See this tip sheetfor a better portal experience when submitting preauthorization requests,.
If you still have questions or need additional support, contact Provider Customer Service using the provider portal’s Message Center or live agent chat.
Free Patient Management and ICD-10 Coding Webinars
EmblemHealth works with Veradigm to offer free monthly webinars to help educate providers on best practices for the risk adjustment process. This includes accurate medical record documentation and claims coding to capture the complete health status of each patient.
The Veradigm webinars are held on Tuesdays and Thursdays; one in the morning and one in the afternoon. View topics and dates here. Click the Register button, then the Public Event List link, and search by webinar date or title of interest.
Here are the upcoming topics:
April 22/24: Setting the Stage for Coding and Documentation for Chronic Kidney Disease.
May 27/29: Inhale the Facts of Coding and Documentation for Common Pulmonary Conditions.
EmblemHealth also works with Veradigm to promote risk adjustment and gap-closure education for primary care providers caring for EmblemHealth members enrolled in these products:
NY State of Health.
Medicare HMO.
Medicaid.
If you have any questions, or you would like to set up a private session for your practice, please email Veradigm at providerengagement@veradigm.com or call Veradigm's Customer Support team at 410-928-4218, option 7, from 8 a.m. to 8 p.m., Monday through Friday.
EmblemHealth Neighborhood Care and ConnectiCare Centers
Our EmblemHealth Neighborhood Care locations and 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 upcoming events for EmblemHealth Neighborhood Care and ConnectiCare Centers.
Keep Your Directory and Other Information Current
Let Us Know When Directory Information Changes
If a provider in your practice is leaving, please inform us as soon as possible. To report other changes, as required by our participation agreements, sign in to your Provider/Practice Profile for EmblemHealth or ConnectiCare. If you participate with us under a delegated credentialing agreement, please have your administrator submit these changes. See more on how to submit changes for EmblemHealth and ConnectiCare.
Remember to review your CAQH application every 120 days and ensure you have authorized EmblemHealth as an eligible plan to access your CAQH information.
Consult EmblemHealth’s Online Provider Manual for Important Information
The EmblemHealth Provider Manual is a valuable online resource and an extension of your Provider Agreement. It applies to all EmblemHealth plans and includes details about your administrative responsibilities and contractual and regulatory obligations. You can also find information about best practices for interacting with our plans and how to help our members navigate their health care. A key resource is the Access & Availability Standards which set up the expected time frames for appointment availability, appointment wait times, and after hours coverage. You can find the EmblemHealth Provider Manual in the top navigation menu of our provider website.