EmblemHealth Site of Service Rules for Certain Surgeries Start Aug. 1
Women’s Health: Osteoporosis and Treating Fractures
MEDICARE UPDATES
Do Not Bill Members With Full Medicaid or QMB
CLAIMS CORNER
Reimbursement Policies
CLINICAL CORNER
Preauthorization Updates
PHARMACY
Pharmacy Preauthorizations
MEDICAL POLICY UPDATES
Medical Policies
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
More Helpful Portal Tips and Improvements
The Message Center has a new feature: “All Messages.” You can now see and follow up on the messages submitted by others who have the same security settings as you.* Similarly, they will be able to see your messages, join the conversation, and attach supporting documentation. Communications with Provider Customer Service for the last two years will be available, including those originating outside the portal.
The messages change is being made to support better collaboration and to reduce rework. Shared access to these messages makes it easier for staff to cover for one another. For example, to see if someone submitted a grievance or appeal, you can self-serve and look up the submitted messages to determine if one is already recorded before you duplicate the effort. To get to Messages:
Click the user profile icon in your browser’s top right corner. (It looks like a person in a circle.)
A drop-down menu will open.
Select “Inquiries.”
This will take you to the Message Details page. In the top section you will be able to see the opened messages you have sent or received. Click on “All Messages” to search by tax ID (required) and NPI (optional) for inquires others submitted. These will display in the second section of the screen.
*Anyone who can conduct business for the same provider, i.e., has the same tax ID, NPI, and same portal role (e.g., Clinical Staff, Billing Staff, etc.).
New: Update diagnosis codes before submitting requests and notices
If you are entering a preauthorization request or elective inpatient admission notification (requests and notices) and the member’s diagnosis changes before you submit the request or notice you will be able to update it on the Review Details page. For a better portal experience when submitting requests and notices, see this new Tip Sheet.
EmblemHealth Site of Service Rules for Certain Surgeries Start Aug. 1
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 procedures that will not be approved in a hospital outpatient setting.
We are providing 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.
Women’s Health: Osteoporosis and Treating Fractures
Managing osteoporosis is a key quality measure under the Healthcare Effectiveness Data and Information Set (HEDIS®) and an important part of delivering needed care to our older members.
Be sure to assess women 67 – 85 years of age who suffered a fracture and prescribe a medication to treat osteoporosis in the six months after the fracture. Also, recommend a bone mineral density (BMD) test.
There are several exclusions:
Patients who had a BMD test during the 730 days (24 months) prior to the episode.
Patients who had a claim/encounter for osteoporosis therapy during the 365 days (12 months) prior to the episode.
Patients who received a dispensed prescription or had an active prescription to treat osteoporosis during the 12 months prior to the episode.
Helpful tips to close gaps in care:
Ask all female patients 67 – 85 years of age if they have had a fracture since their last visit.
Consider writing a prescription for a BMD test at time of fracture.
If patients are unable or unwilling to have a BMD test, prescribe osteoporosis medications if appropriate.
Place a reminder in the patient’s chart for a BMD test.
Use telehealth visits to review, document, and prescribe medication, when appropriate.
Educate patients on safety and fall prevention.
By following these recommendations, you can help improve patient health outcomes.
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.
The following reimbursement policies have been updated. Please refer to the website applicable to the member’s plan (EmblemHealth | ConnectiCare) and see the revision histories for effective dates and applicable changes. Laboratory Benefit Management program policies have “(LBM)” at the end of their names.
Biomarker Testing for Autoimmune Rheumatic Disease (LBM).
Coding Edits Policy.
Colorectal Cancer Screening (LBM).
Diagnosis of Vaginitis (LBM).
DME Rental vs. Purchase Reimbursement Policy.
Flow Cytometry (LBM).
Helicobacter Pylori Testing (LBM).
Human Immunodeficiency Virus (HIV) (LBM).
Modifier Reference Reimbursement Policy.
Onychomycosis Testing (LBM).
Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing (LBM).
Pediatric Preventive Screening (LBM).
Prenatal Screening-(Nongenetic) (LBM).
Prescription Medication and Illicit Drug Testing in the Outpatient Setting (LBM).
Preventive Care Services Commercial and Medicare.
Prostate Specific Antigen (PSA) Testing (LBM).
Salivary Hormone Testing (LBM).
Split/Fragmented Billing Reimbursement Policy.
Thyroid Disease Testing (LBM).
Urinary Tumor Markers for Bladder Cancer (LBM).
Clinical Corner
Preauthorization Updates
As part of our annual review process, EmblemHealth is removing 303 services and codes from the EmblemHealth Preauthorization List.
In addition, we are adding five new codes, expanding some existing preauthorization requirements to additional members. Also, as shared in EmblemHealth Site of Service Rules for Certain Surgeries Start Aug. 1and in our Notable Changes, starting Aug. 1, 2025, some codes will require preauthorization when performed in an outpatient hospital setting, places of service (POS) 19 and 22 for members under 75 years of age.
EmblemHealth and ConnectiCare update their claims processing systems based on code updates received from American Medical Association (AMA), CPT, and Centers for Medicare & Medicaid Services (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:
May 27/29: Inhale the Facts of Coding and Documentation for Common Pulmonary Conditions
June 24/26: Pulse Check: Accurate Coding and Documentation for Cardiovascular 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.
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 Standards, which sets up the expected time frames for appointment availability, appointment wait times, and after hours coverage. (Also see: ConnectiCare’s Access & Availability Standards.)