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
Oral HIV Pre-Exposure Prophylaxis (PrEP)
Oral PrEP, a medication used for HIV-negative individuals at risk of exposure, is up to 99% effective in preventing HIV acquisition from sex and at least 74% effective from injection drug use. When a patient needs a PrEP prescription, consider which option will save them money and support their adherence to their medication regimen.
Our members may be eligible for a zero-dollar copay. See our flyer for zero-dollar copay criteria and a comparison of the FDA-approved oral treatment options for PrEP: Descovy® and Truvada®.
We ask our New York providers to consider registering for inclusion in the New York State Department of Health PrEP Prescribers directory.
Here are a few resources for you and your patients:
To avoid claims denial and the need to submit corrected claims, please make note of the following when billing telehealth and virtual care services in 2025. To maintain payment parity between in-person and telehealth visits for services rendered in 2025, continue to use the existing office visit procedure codes with appropriate modifiers and place of service codes.
Since Current Procedural Terminology (CPT) code G2012 has been retired, CPT Code 98016 may be used in its place for brief virtual check-in visits with established patients. Otherwise, EmblemHealth and ConnectiCare are not accepting the new telehealth codes for 2025. See our Telehealth/Virtual Care Services reimbursement policy.
New Vaccine Resources for Members
We have a new online member resource you can share with your patients to help raise awareness of yearly preventive vaccines.
As you know, children, adults over 65, and people with chronic conditions such as asthma, are at a higher risk of flu complications. We encourage vaccination among this population and for people who are pregnant or have recently had a baby.
As our partner in our members’ health care, please talk to your patients about the importance of vaccinations. To see a summary of the various seasonal vaccines we recommend and basic coverage information, visit EmblemHealth | ConnectiCare.
Colorectal Cancer Awareness
In recognition of Colorectal Cancer Awareness Month, we encourage you to take this opportunity to teach patients about the importance of prevention and treatment.
Colorectal cancer screening should begin at age 45 for those with average risk and continue until age 75. EmblemHealth covers colorectal cancer screening for members with $0 cost-share.
Available testing options:
Guaiac-based fecal occult blood test (gFOBT) every year.
Fecal immunochemical test (FIT) every year.
Stool DNA-FIT test every one or three years.
Flexible sigmoidoscopy every five years.
Flexible sigmoidoscopy every 10 years plus FIT every year.
Colonoscopy every 10 years.
The following resources can help you educate patients:
National Kidney Month is the perfect opportunity to teach patients about the importance of screening to help prevent kidney disease. It’s especially important for patients with chronic conditions such as diabetes and high blood pressure who are at high risk for developing kidney disease.
Here are some ways to help your patients who may be unfamiliar with kidney disease or unaware of ways to maintain kidney health.
Teach patients about the importance of diet, exercise, nutrition, weight control, and sleep.
Encourage patients to manage their blood sugar. People with diabetes, or a condition that causes high blood sugar, may develop into kidney damage.
Encourage patients to monitor blood pressure. High blood pressure can cause kidney damage. If high blood pressure occurs with other health issues like diabetes, heart disease, or high cholesterol, the impact on the body can be significant.
Actions for you to take to help your patients and be compliant with the Quality measure – Kidney Evaluation for Patients With Diabetes (KED):
Create a treatment plan for at-risk patients that fits their lifestyle and dietary needs.
Order a kidney health evaluation annually for all patients with Type 1 or Type 2 diabetes. This evaluation should includeBOTH tests:
Estimated glomerular filtration rate (eGFR).
A urine albumin-creatinine ratio (uACR) identified by either of the following:
Both a Quantitative Urine Albumin test and a Urine Creatinine test with service dates four days or less apart.
Urine Albumin Creatinine Ratio test (uACR).
Here are some resources you can share with your patients:
All hospitals and critical access hospitals are required by CMS 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.
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:
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 processwill 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.
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:
Feb. 25/27: The ABC’s of Coding for Common Pediatric Conditions.
March 25/27: Health Equity: Ensuring You Are Properly Coding and Documenting for SDOH Disparities.
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, The Official Health Plan Marketplace 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.
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 use our Referral Form to send your patients to us. See ConnectiCare Centers’ website for their locations and events.
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. 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 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, emblemhealth.com/providers.