New Specialty Pharmacy Requirement in Effect for EmblemHealth
Pharmacy Preauthorizations
MEDICAL POLICIES
Medical Policies Updates
MEDICARE UPDATES
Do Not Bill Members With Full Medicaid or QMB
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
ALERT
CMS Issues Fraud Warning
The Centers for Medicare & Medicaid Services (CMS) recently posted a warning on its website about an emerging fraud scheme. See full announcement.
Feature Stories
Bolster Immunization Rates This Summer
Summertime, when pediatric office visits are typically low, is a good time to get your young patients up to date on their vaccines, immunizations, and boosters.
As you know, children, preteens, and teens have specific vaccination requirements and certain immunizations are recommended at specific ages. As they visit your office to comply with school or day care requirements, talk to their parents about the importance of vaccinating their children and help improve immunization rates.
For children who may not have been to your office in a while, reach out to their parents and encourage them to schedule an appointment for their child.
Here are some helpful tips to engage with parents.
Review and ensure accurate and thorough chart preparation before the appointment.
Review charts for immunization gaps.
Educate your care teams about scheduling visits within the guideline time frames.
Continue to ensure at each appointment (even sick visits), that immunization records are reviewed and encourage them to catch up on missed immunizations.
Advise parents on the importance of timely completion of each vaccine series.
Provide handouts on the diseases/illnesses that the vaccines prevent.
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.
New Specialty Pharmacy Requirement in Effect for EmblemHealth
As of July 14, 2025, EmblemHealth participating outpatient providers — including outpatient hospitals, physician offices, member homes, and ambulatory infusion centers — are required to obtain certain drugs from specific specialty pharmacies.
Commercial and Medicare coverage of the Abbott Alinity™ m STI Assay, Guardant Shield, and IsoPSA®tests.
NavDx Medicare Coverage.
·Immunoscore® as investigational for all members.
EmblemHealth updated the Clinical Trials (Medicare) medical guidelines to add language clarifying that Category B devices that are integral to CMS-approved Category B Investigational Device Exemption (IDE) trials are covered.
EmblemHealth updated the Radiofrequency Ablation of Tumors medical guidelines to add nonmetastatic desmoid tumors to the investigational list.
ConnectiCare updated the Clinical Trials (Medicare) medical guidelines to add language clarifying that Category B devices that are integral to CMS-approved Category B Investigational Device Exemption (IDE) trials are covered.
ConnectiCareupdated the Radiofrequency Ablation of Tumors medical guidelines to add nonmetastatic desmoid tumors to the investigational list.
Medicare Updates
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 (QMB), 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 EmblemHealth members, use ePACES to check whether the member has full or partial Medicaid benefits. For more details see EmblemHealth Medicare Advantage Plans.
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:
July 29/31: The Sweet Spot: Coding for Diabetes and Complications
Aug. 26/28: Don’t Let Coding Get Under Your Skin: Coding and Documentation for Dermatology Disorders
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.
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. 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.
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, and After-Hours Coverage Standards, which set up the expected time frames for appointment availability, appointment wait times, and after hours coverage.