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Feature Stories
ConnectiCare in the Community
Social interactions are important in maintaining overall health and well-being. Encourage your patients to actively seek out opportunities to engage with others.
Pictured are ConnectiCare volunteers with Hartford Mayor Arunan Arulampalam and Lt. Governor Susan Bysiewicz at the recent 10th Annual CT Latino Fest in Hartford.
Below are some upcoming community events for your patients to join:
Rockwell Park Summer Festival takes place in Bristol on Saturday, Aug. 16, from 10 a.m. to 6 p.m., featuring vendors, bands, food trucks, arts and crafts, a kid’s zone, car show, and more.
The Greater Hartford Puerto Rican Day Parade and Festival will begin along the Park Street parade route on Sunday, Sept. 21 at noon, featuring nearly 3,000 marching participants.
Yoga In Our City has free classes all summer long in local city parks. Classes are open to everyone, regardless of age or skill level. Check out the full schedule.
Upcoming Events at Our ConnectiCare Centers
Our ConnectiCare Centers provide one-on-one customer support to help members understand their health insurance plan. Our centers also 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.
Let your patients know about this upcoming event:
Mobile mammography will be available at the ConnectiCare Center in Manchester on Tuesday, Aug. 26, from 8 a.m. to 1 p.m. Take the Time is Hartford Hospital’s digital mobile mammography program that brings convenient, accessible screenings to locations across Connecticut.
Lowering Medication Costs for Our Medicare Members
EmblemHealth is committed to helping our Medicare population manage their medication costs.
Starting Aug. 18, 2025, when we identify potential cost-saving prescriptions for our members, we will fax the member’s information and the cost-saving alternative(s) to the prescribing provider for consideration.
The prescriber will need to review, complete, and fax the attached form back to us to authorize the recommended change or indicate why the switch is not appropriate.
Exception for controlled substances
To accept the recommended change for a controlled substance, the prescriber will need to both fax the authorization order form back to us AND send the prescription change via electronic health record directly to the member’s pharmacy.
Help Older Members Age Healthfully
By the year 2030, adults aged 65 and older are projected to outnumber children for the first time in U.S. history.
Promoting health and preventing disease in older Americans is key to the nation’s health. As we age, physical and cognitive function may decline, and pain may affect quality of life. Older people may also have more complex medication regimens.
Here are some best practices to consider for your 65-and-over patients:
Incorporate a standardized checklist to capture functional status, pain status, and any medications the member may take.
Complete a functional status assessment and pain assessment at every face-to-face and telehealth visit.
Ensure the medical record contains the member’s medication list.
Document in the medical record if the member is not taking any medication.
The Centers for Disease Control and Prevention’s (CDC) Still Going Strong campaign speaks directly to older adults and their caregivers. Resources are available to download and share. Please also see information about EmblemHealth’s free Care for the Older Adult program.
Raising awareness about preventable injuries among older adults and simple steps people can take to stay healthy and independent longer can be found in the campaign. Getting older doesn’t mean your patients have to give up the activities they enjoy.
Claims Corner
Payment Integrity Policies
The EmblemHealth(CMS and Medicaid)and ConnectiCare (CMS) Annual Fee Schedule Update payment integrity policies were updated to reflect single company branding. In addition, the EmblemHealth policy added clarification to the Medicaid section regarding retroactive adjustments.
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. Refer to the website applicable to the member’s plan (EmblemHealth | ConnectiCare) and see the revision histories for effective dates and applicable changes. Lab Benefit Management policies have “(LBM)” after the policy name.
Ambulatory Surgical GroupersReimbursement Policy.
Biomarkers for Myocardial Infarction and Chronic Heart Failure (LBM).
Bundled Services (Commercial and Medicare) Reimbursement Policy.
Cardiovascular Disease Risk Assessment (LBM).
Coding Edits Policy.
Coding Edits Reimbursement Policy.
Computer Assisted Surgical Navigation.
ConnectiCare Preventive Care Services (Commercial and Medicare).
Coronavirus Testing in the Outpatient Setting (LBM).
EmblemHealth Preventive Care Services (Commercial).
EmblemHealth Preventive Care Services (Medicare).
Folate Testing (LBM).
General Inflammation Testing (LBM).
Hepatitis Testing (LBM).
Identification of Microorganisms Using Nucleic Acid Probes (LBM).
Laboratory/Venipuncture Reimbursement Policy.
Modifier Reference Reimbursement Policy.
Pancreatic Enzyme Testing for Acute Pancreatitis (LBM).
Pathogen Panel Testing (LBM).
Preventive Care Services (Commercial) Reimbursement Policy.
Preventive Care Services (Medicare) Reimbursement Policy.
Robotic Surgery.
Serum Testing for Evidence of Mild Traumatic Brain Injury (LBM).
Serum Tumor Markers for Malignancies (LBM).
Sign Up for EFT With PNC ECHO
We’d like to remind and encourage all our providers to sign up for electronic funds transfer (EFT) if you haven’t already done so.
EmblemHealth has partnered with PNC/ECHO Health Inc. for the past five years to handle our claims payments and remittances (CPR) for our providers.
This arrangement with PNC/ECHO simplified our claims payment process by using one system for all payments. CPR can handle electronic payments reliably for multiple payment types. A major advantage of automated payments is the ability to receive an 835/ERA with each EFT payment. In addition, EFT payments:
Increase speed of receiving payments
Significantly reduce payment processing costs
Streamline the accounts receivable (A/R) process
Reduce fraud exposure
Improve the accuracy and timeliness of information
For EFT/ERA enrollment and additional assistance regarding payment, contact ECHO Provider Support at 888-492-0032or visit their website.
If you have other questions about this process, please sign in to the provider portal at emblemhealth.com/providerportal and use our live agent chat or Message Center to contact us. A Provider Customer Service Representative will be happy to help.
Clinical Corner
Preauthorization Updates – Quarterly Code Updates
EmblemHealth and ConnectiCare update their claims processing systems based on code updates received from American Medical Association (AMA), CPT® and 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 processholds 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 EmblemHealth medical guideline for Gene Expression Profiling has been revised to include positive AlloSure® kidney and AlloSure lung coverage for Commercial and Medicaid members.
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.
Training Opportunities
Provider Portal Videos and Guides
If you need help navigating our provider portals, please see our videos, quick guides, and Frequently Asked Questions pages:
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:
Aug. 26/28: Don’t Let Coding Get Under Your Skin: Coding and Documentation for Dermatology Disorders
Sept. 23/25: Making Connections: Proper Coding and Documentation for Neurological 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 plans.
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.
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 EmblemHealth and ConnectiCare.
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 ConnectiCare as an eligible plan to access your CAQH information.