Elektra Health Can Help Your Patients Through Menopause
PHARMACY
New Specialty Pharmacy Requirement Starts July 14
MEDICAL POLICIES
Medical Policies 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
ConnectiCare and Molina Healthcare
On Feb.1, 2025, ConnectiCare was acquired by Molina Healthcare. Molina is a growing company with more than 40 years of experience serving 5.1 million members across 22 states. We are excited about the opportunities that Molina will bring to Connecticut. Their expertise and commitment to the communities they serve will allow us to make improvements for our members and your patients.
We know this change comes with a lot of questions for our network providers — our valued partners. These Frequently Asked Questions cover some preliminary information we can share at this time. In the coming months, we will provide you with the details you need to facilitate a smooth transition as ConnectiCare is integrated into the Molina family.
In the meantime, please continue to follow current ConnectiCare processes and procedures. Stay tuned for future communications from us as we will continue to send details about this change and our 2026 plans as soon as we can. Until then, if you would like to get in touch, sign in to the ConnectiCare provider portal to contact us through the Message Center.
National HIV Testing Day is June 27
June 27 is National HIV Testing Day. This annual recognition serves as a reminder to talk to your patients about being tested for HIV.
According to the Centers for Disease Control and Prevention (CDC), HIV testing is the pathway to engage people in their care. When patients are aware of their HIV status, it can help them choose options to stay healthy, regardless of their test results.
Here’s a video from the Centers for Disease Control and Prevention focused on clinicians having a discussion about HIV testing with their patients.
Make Summer Plans for Dental and Wellness Visits
Well-Child Visits (WCV) You can conduct or schedule well-child visits when patients come to your office for illnesses or other events. You don’t need to wait 365 days between well visits. This means children no longer must wait 12 months from the date of their last wellness visit to be covered for an annual wellness visit. The claim modifier for separate and distinct services should be added. Telehealth can be used for well-child visit compliance but be sure to submit the appropriate CPT with GT modifier.
This measure is based on the American Academy of Pediatrics Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents (published by the National Center for Education in Maternal and Child Health). Visit Bright Futures for more information about well-child visits.
Oral Evaluation, Dental Services (OED) When seeing your pediatric patients, talk to their families about the link between oral and overall health, and encourage routine dental visits beginning as early as age one, or first tooth eruption.
No referral is required to see a dental provider.
Inform the family of the link between oral health and overall health.
Encourage routine visits beginning as early as age one or first tooth eruption.
Regular checkups are important at all ages, so be sure to schedule annual wellness visits for all your 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. Refer to the website applicable to the member’s plan (EmblemHealth | ConnectiCare) and see the revision histories for effective dates and applicable changes.
Coding Edit Rules (11 new edits start July 4, 2025)
EmblemHealth’s Preventive Care/Screening (Commercial and Medicaid)
Emergency Department (ED) Facility E&M Coding (Commercial and Medicare)
Discarded Drugs/Biologicals – Modifiers JW and JZ (Commercial)
Telehealth/Virtual Care Services
Clinical Corner
Importance of Using Participating Laboratories
EmblemHealth Policies and Procedures and your Participation Agreement with us state that you should refer your EmblemHealth members to participating laboratories. Using an in-network lab helps keep costs down; making care more affordable for members.
EmblemHealth has provider contracts with Quest Diagnostics and Labcorp, as well as contracts with other participating laboratories for outpatient lab testing. If you do not have an account with Quest Diagnostics or Labcorp, you may establish one by contacting them as follows:
Starting Aug. 1, 2025, EmblemHealth will require preauthorization for certain hospital outpatient surgeries (places of service 19 and 22) for all members under age 75. Only surgeries that are clinically appropriate in a hospital setting will be approved. See Notable Changes for the specific services and codes that will require preauthorization along with other changes to the list including the removal of 303 services.
The same surgeries scheduled in an ambulatory surgery center (ASC) or physician office will not require preauthorization. Surgeons are encouraged to obtain privileges at an ASC so their patient’s insurance can cover those procedures that will no longer be approved in a hospital outpatient setting.
We provided advance notice of this change to allow surgeons a three-month grace period to partner with an ASC. To find a participating ASC that is accepting new doctors for the surgeries you perform, see this list. For questions, send a message to our Provider Customer Service team using the provider portal’s Message Center or live agent chat.
Elektra Health Can Help Your Patients Through Menopause
To help members with their journey from perimenopause through postmenopause, ConnectiCare and EmblemHealth’s provider networks now include Elektra Health, a specialized women’s health virtual care and education provider. They offer valuable information and expertise for managing menopause, which can supplement the care you give your patients. For details see:
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.
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:
June 24/26 — Pulse Check: Accurate Coding and Documentation for Cardiovascular Conditions
July 29/31 — The Sweet Spot: Coding for Diabetes and Complications
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 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.