Responses Due March 29 for Annual HEDIS Medical Record Review
MEDICARE UPDATES
Do Not Bill Members With Full Medicaid or QMB
CLAIMS CORNER
Reimbursement Policies
CLINICAL CORNER
Importance of Using Participating Labs
Preauthorization Updates
PHARMACY
NEW: Commercial Formulary Search Tool
MEDICAL POLICIES
Medical Policy Updates
TRAINING OPPORTUNITIES
Provider Portal Videos and Guides
Free Patient Management and ICD-10 Coding Webinars
Valuable Training Available
IN THE NEWS
Abdou Bah a 2025 Black Power Player
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
Member Engagement—CAHPS Season is Here
We all play an important role in impacting our members’ experience. This is captured every year through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey—and your interactions with patients has a direct impact on their response to the survey.
The CAHPS survey measures patients’ perception of their providers and their health plan. High CAHPS survey scores reflect positive relationships between our members and their providers, as well as their ability to access timely, well-coordinated care.
Here are some tips to help you provide the best care to your patients and maximize your CAHPS survey performance:
Engage in two-way communication.
Communicate in plain language. Explain the care provided and treatment plan in a way that is easy to understand. Listen carefully. Make sure patients also understand the care they receive from other providers.
Evaluate the need for increased appointment availability.
Consider offering same-day appointments, evening and weekend appointments, an after-hours nurse line, and virtual visits.
Equip patients with tools.
Give members take-home material about their health conditions. Implement reminder systems and offer options to get their health records.
Consider timeliness.
Limit telephone hold times to under 15 minutes and keep patients informed if you are running behind schedule. Try to schedule well visits/routine physicals within four weeks and non-urgent sick visits within 48 to 72 hours of their request.
Learn more about CAHPS and how to improve your scores.
PCMH Payments To Be Issued in April
EmblemHealth is adopting and incorporating recent Patient-Centered Medical Home (PCMH) payment guidance from New York State (NYS) for eligible practitioners.
As a result, we will issue payments in April 2025 at the updated rates for applicable members who have selected you as their primary care physician during the months of April 2024 up to and including September 2024. This will include retroactive payment adjustments for the providers who were already paid for services rendered during the months of April 2024, May 2024, and June 2024. We will later be issuing payments for applicable members who have selected you as their primary care physician during October 2024 and up to and including March 2025.
EmblemHealth will continue to adjust the current payment schedule for the calendar year (two separate payments will be made: one payment for members who have selected you as their primary care physician during January and up to and including June, and a second payment will be made for applicable members who have selected you as their primary care physician during July and up to and including December) to align with the state fiscal year payments received by EmblemHealth. Payment amounts will be determined by the NCQA’s Patient-Centered Medical Home Recognition Program level achieved after meeting specific elements in nine standard categories, in conjunction with the number of Medicaid, HARP, and Child Health Plus patients who have selected the eligible practitioner as their primary care physician (panel size).
EmblemHealth works with Veradigm to promote risk adjustment education and gap closure efforts for EmblemHealth members.
The 2025 EmblemHealth Risk Adjustment Program for Primary Care Providers (PCPs) is underway and runs from Jan. 1, 2025, through Dec. 31, 2025. The program is designed to help our PCPs identify members with chronic conditions who require an annual evaluation. The program also supports correct coding and documentation of the severity of their condition.
We look to our PCPs to maintain accurate medical records and claims coding to capture the complete health status of all NY State of Health members, Medicare Advantage HMO members, and Medicaid members.
EmblemHealth needs evidence of ongoing care to support accurate reimbursement for government programs. As a bonus, PCPs who also complete a compliant provider alert and provide the supportive progress note(s) in Veradigm’s Collaborate provider portal can receive additional reimbursement.
2025 Collaborate Provider Portal Collaborate is a web-based tool that supports improvements in documentation, quality, and risk score accuracy. PCPs can visit Veradigm’s Collaborate provider portal via the EmblemHealth provider portal at emblemhealth.com/providerportal. Seeinstructions for using the Veradigm Collaborate portal.
If you are interested in learning more about how you can view Veradigm’s provider resources and webinars, contact Veradigm’s Customer Support team at 800-877-5678,option 7, from 8 a.m. to 8 p.m., Monday through Friday or email support@veradigm.com.
Responses Due March 29 for Annual HEDIS Medical Record Review
Many providers may have already received letters from our Quality Management department as part of our annual medical record review. This is a required review for Healthcare Effectiveness Data and Information Set (HEDIS) reporting, Regulatory State reporting, and by the Centers for Medicare & Medicaid Services (CMS).
Compliance with HEDIS data collection is part of your Participating Provider Agreement(s). HEDIS and CMS consider missing records as noncompliant. Therefore, if you receive these letters — which contain a list of patients for whom we need medical records and a HEDIS Medical Record tip sheet — send us back the patient list and the section of the patient chart that shows the HEDIS measure has been met. The return fax number and secure email instructions will be noted in the letter.
NOTE: If you use outside vendors to collect medical records, it is your contractual obligation to make members’ medical records available to the plan — at no charge — for these reviews.
We appreciate your cooperation and thank you in advance for your prompt response. If you have any questions or concerns, call our HEDIS Helpline at 631-844-2420.
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.
Starting June 13, 2025, EmblemHealth and ConnectiCare are introducing a new laboratory benefit management reimbursement policy to address therapeutic drug monitoring of 5-Fluorouracil. See:
The following reimbursement policies have been updated. If the policy does not have a company name shown, the policy applies to both EmblemHealthand ConnectiCare. See their revision histories for effective dates and applicable changes:
Coronavirus Testing in the Outpatient Setting (LBM)
Diabetes Mellitus Testing (LBM)
Diagnosis of Idiopathic Environmental Intolerance (LBM)
Diagnostic Testing of Iron Homeostasis & Metabolism (LBM)
Testing of Homocysteine Metabolism-Related Conditions (LBM)
Testosterone Testing (LBM)
Vitamin B12 & Methylmalonic Acid Testing (LBM)
Vitamin D Testing (LBM)
Clinical Corner
Importance of Using Participating Labs
In accordance with EmblemHealth Policies and Procedures and your Participation Agreement with us, please remember to refer your EmblemHealth members to participating laboratories.
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:
For a better portal experience when submitting preauthorization requests, see this newtip sheet.
Pharmacy
NEW: Commercial Formulary Search Tool
Participating providers can now refer to these commercial formulary search tools (EmblemHealth | ConnectiCare) for help in selecting cost-effective drug therapies. Using the search tool, providers can find important information including:
Formulary status of a drug
Coverage details and/or limitations
Drug information
Other drug options
The pharmacy programs for commercial members are based on a tiered system. The tiers group preferred/non-preferred products for generics, brands, and specialty drugs. For more information on each tier and drug list, refer to EmblemHealth Formularies and the ConnectiCare’s Pharmacy Center.
Consolidate Decipher and Prolaris sections and updated criteria.
Add FoundationOne RNA and Prospera as investigational (covered Medicare).
Update Signatera investigational listing to communicate positive Medicare coverage.
Add notation to PancraGen investigational listing to communicate Medicare non-coverage starting Feb. 7, 2025.
The EmblemHealth and ConnectiCare medical guidelines for Fetal Surgery has been updated to added fetal cystic hygroma as a covered indication.
The EmblemHealth and ConnectiCaremedical guidelines for Varicose Vein Treatment has been updated to:
Change the timeframe from six months to 90 days for recurrent episodes of superficial thrombophlebitis and/or persistent symptoms interfering with daily living activities.
Remove three-month trial of conservative non-operative treatment (e.g., leg elevation, compression stockings) as a prerequisite for procedures.
Remove note stipulating that there should be no thrombosis that would interfere with intraluminal procedures
Remove note stipulating that sclerotherapy should not occur sooner than three months after an ablation procedure.
·Defined prerequisite accessory saphenous reflux time as > 500 msec.
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:
March 25/27: Health Equity: Ensuring You Are Properly Coding and Documenting for SDOH Disparities
April 22/24: Setting the Stage for Coding and Documentation for Chronic Kidney Disease
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.
Congratulations to Senior Vice President of Medical Management and Chief Health Equity Officer, Abdou Bah, on being recognized as a 2025 Black Power Player by amNYmetro and Politics NY. Learn more.
In Every Issue
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
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.