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2021-2022 Annual Provider Notification

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2021-2022 Annual Provider Notification

Group of doctors cooperating while reading medical analysis on a computer at doctor's office.

What to Expect for 2022 & 2021 Year in Review

 

Our thanks to you, our partners, for the care you give our members. We appreciate your efforts and respect the time you take to provide quality care.

 

We are committed to identifying ways to reduce time spent on administrative transactions.* We’re doing this to give you more time with your patients. For instance, we will be further reducing the number of codes on preauthorization lists for all members in 2022.

 

Over the summer, we launched a new provider portal that makes it easy to keep your directory information up to date, manage key transactions, and much more. See the Clinical Corner and Your Resources sections below for details.

 

Please review and share the materials below with your clinicians and staff. This streamlined recap of 2021 guidance and what you’ll need to know for 2022 will help you care for your patients.

 

As always, for guidance and reference on regulatory, policy, and accreditation requirements (such as provider rights, member rights and responsibilities, availability of criteria, and pharmacy procedures), visit our comprehensive Provider Manual here: https://www.emblemhealth.com/providers/manual. Below are some of the more in-demand links from the Provider Manual:

 

Information Link
Credentialing Information https://www.emblemhealth.com/providers/manual/credentialing
Member Rights and Responsibilities https://www.emblemhealth.com/providers/manual/member-policies-andrights
Pharmaceutical Procedures https://www.emblemhealth.com/providers/manual/pharmacy-services
Care Management https://www.emblemhealth.com/providers/manual/care-management
Provider Portal https://www.emblemhealth.com/providers/resources/provider-sign-in
Behavioral Health Services
 https://www.emblemhealth.com/providers/manual/behavioral-health-services

 

*Members assigned to Montefiore CMO, HealthCare Partners, and SOMOS will continue to follow their administrative processes and will need to submit ER admission/newborn notifications directly to them. Our vendor partners who manage our Utilization Management Programs will continue to use their own websites and provider portals for transactions.

2022 Network and Benefit Plans

Our 2022 Summary of Companies, Lines of Business, Networks, and Benefit Plans is an extension of our provider agreement(s). It defines our 2022 offerings.

Refer to this list of 2022 Benefit Plans That Do Not Require a Referral when scheduling appointments.

Select the links below to learn about our 2022 plans as well as key operational, training, and regulatory requirements. The links now go to permanent webpages where you will be able to find product-specific information all year long:

For your reference, also see:

Dental Network Changing from DentaQuest to Healthplex in 2022

Our dental partner will be changing in 2022 from DentaQuest to Healthplex. Members who need dental care should be directed to our Find a Doctor directory. If additional assistance is needed, please contact Healthplex at 888-468-2183, Monday to Friday from 8 a.m. to 5 p.m.

Improving the Patient Experience, Timely Access to Care, and Continuous Quality Improvement

At EmblemHealth, we value our members' experience with us and with you, our contracted providers. A member's experience often begins with their use of our provider directories. We ask you to keep your listings current. Once they have found the right provider, their next experience is appointment scheduling. Members expect their providers to schedule timely appointments and to know whether services need referrals or preauthorizations. They expect to be treated with dignity, in a culturally competent manner, free from discrimination, and to have their rights honored. We also expect our members to respect you and to honor their responsibilities.   

 

Health care professionals have the greatest impact on clinical outcomes. Those who follow established guidelines and best practices are successfully increasing quality measure scores and patient satisfaction. The following includes information to help you meet members' expectations and outlines the ways that we are measured in meeting them.     

   

Easy Access Resources   

   

Keep your directory information current  

Please review your listings in our online directory so our members can find you. If something is not right, please let us know based on how you participate with us:  

  • If you work for an organization that is delegated for credentialing, please ask your practice administrator to include the correction on the next dataset submission.  

  • If your application was credentialed directly by EmblemHealth’s staff, review and make changes to your profile by signing in to your account.  

  • If you do not have computer access, please send changes to our Provider Modifications team:  

    • By fax: 877-889-9061 

    • By mail: EmblemHealth, Attn: Provider Modifications, 55 Water Street, New York, NY 10041  

   

Are You Accessible to Your Patients?  

Offering timely appointments and having coverage after hours is not only a contractual requirement, it is a key concern for our members. EmblemHealth and the Department of Health conduct audits to see if you’re accessible to your patients. You should become familiar with the “Appointment Availability Standards During Office Hours & After Office Hours Access Standards” located in the Provider Toolkit. You may also download it here.  Please post these standards in your office for your appointment schedulers. Failure to comply with these standards may result in termination from our network. The standards also include a list of avoidable mistakes that count as audit failures. Please take the time to review these common errors to prevent them from happening to you.  

 

 Nondiscrimination rule  

Practitioners shall comply with all applicable laws prohibiting discrimination against any member and in accordance with the same standards and priority as the provider treats his/her/their other patients regardless of any of the following factors:  

  •  Age  

  • Amount of payment  

  • Claims experience  

  • Color  

  • Creed  

  • Disability  

  • Ethnicity  

  • Evidence of insurability (including conditions arising out of acts of domestic violence)  

  • Gender  

  • Genetic information  

  • Health literacy  

  • Health needs  

  • Health status  

  • HIV status  

  • Language  

  • Marital status  

  • Medical history  

  • Mental or physical disability or medical condition  

  • National origin  

  • Need for health services  

  • Place of residence  

  • Plan membership  

  • Race  

  • Religion  

  • Sex  

  • Sexual orientation  

  • Source of payment  

  • Type of illness or condition  

  • Type of insurance coverage 

  • Veteran status  

  •  In addition, providers are to comply with:  

    • Age Discrimination Act of 1975  

    • Americans with Disabilities Act  

    • Title VI of the Civil Rights Act of 1964  

    • Terms of the plan’s contracts with NYSDOH and/or CMS  

    • Health Insurance Portability and Accountability Act  

    • HIV confidentiality requirements of Article 27-F of the Public Health Law and Mental Hygiene Law  

    • Section 1557 of the Affordable Care Act (ACA) of 2010  

    • Other laws applicable to recipients of federal funds, and all other applicable laws and rules, as required by applicable laws or regulations  

 

Member Rights and Responsibilities and Your Activities  

Member rights and responsibilities are distributed to new and existing members, and are available to new and existing practitioners in the provider manual. In summary, the rights and responsibilities include their providers:  

  • treating them with respect.   

  • recognizing their dignity.   

  • respecting their right to privacy.   

  • allowing them to participate in making decisions about their health care.   

  • discussing treatment options for their condition(s) candidly regardless of cost or benefit coverage.   

  • voicing complaints or appeals about the organization or care.  

  • making recommendations regarding their rights and responsibilities.  

Members are responsible for:  

  • understanding their health problems.  

  • participating in the development of mutually agreed-upon treatment goals.  

  • following plans and instructions for care to which they have agreed.  

   

Continuous Quality Improvement  

We have adopted a model of Continuous Quality Improvement in medical, pharmaceutical, dental, behavioral health care, and service provided to a complex, culturally and language-diverse membership as a core business strategy. Our Executive and Management teams use data-driven, decision-making methodologies in the strategic planning process. We have adopted the Institute for Healthcare Improvement (IHI) and the Centers for Medicare & Medicaid Services (CMS) Triple-Aim for Healthcare Improvement. We strive to simultaneously improve the health status of our members, improve each member’s experience of care, and reduce the per capita cost of health care. See our Provider Manual to learn more about our Quality Improvement Program.   

   

Performance Management  

Performance related to member care is continuously being assessed by accreditation and regulatory agencies. The goal is to make sure members receive and are satisfied with the most appropriate care for the best possible safe result. Tools used to measure member receipt of and satisfaction with care include:

  • Healthcare Effectiveness Data and Information Set (HEDIS)* and Quality Assurance Reporting Requirements (QARR) – tools which measures care and service provided to members.
  • Health Outcomes Survey (HOS) – allows Medicare patients to report their own current health status.  
  • The Consumer Assessment of Healthcare Providers and Systems (CAHPS®)* and Enrollee Experience surveys are annual surveys used to measure patients’ experiences with the health plan, and access to their doctors and doctors’ offices. These surveys ask about getting appointments and care quickly, ease of getting needed care, ease of communicating with staff and doctors, getting help in coordinating care, flu vaccination, and the overall experience of getting care. Positive experiences result in better survey ratings. The sections below include tips for improving the patient experience which you can apply in your practices.

Here are some non-clinical tips to boost your measurement scores:

  • When billing, use the correct codes which relate to ALL services given during the visit.  
  • Be sure to include the codes with the most specific definition of the diagnosis, procedure, and/or associated result. This may reduce chart collection.  

Remember to:  

  • Bill with appropriate Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and International Classification of Diseases (ICD) codes.  
  • Give the health plan access to the member’s medical record or encounter data.  
  • Closely follow Clinical Practice Guidelines.  
  • Use codes associated with HEDIS/QARR value sets. 

Help your patients get care quickly:

  • Leave open appointments for sick visits and urgent appointments.
  • Ensure patients understand timeline for follow-up.
  • Discuss how to access care after hours.

Assist your patients with getting the care they need:

  • Educate your patients on the importance of preventive services.
  • Follow-up with specialists of patients to ensure continuity of care.
  • Speak at a level appropriate to patients’ education and in their preferred languages.
  • Ask patients what their top health concerns are.
  • Use the teach-back method to ensure understanding.

Care Coordination:

  • Assist in coordination of non-emergency transportation, if necessary.
  • Link patients with community resources to facilitate referrals and respond to social service needs.

*HEDIS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).  

*CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). 

Behavioral Health: Mental Health & Substance Abuse

For full information about our mental health and substance abuse (MHSA) services available to your patients, see the Behavioral Health chapter of the EmblemHealth Provider Manual. We partner with Beacon Health Options (for all members who do not have a Montefiore PCP) and Montefiore University Behavioral Health (only for Monte CMO members) to provide and to manage MHSA services. To find a provider for your EmblemHealth members, use Find A Doctor.  

Collaboration is KEY!  

Physicians are encouraged to collaborate with behavioral health care practitioners and use information to coordinate medical and behavioral health care.  EmblemHealth evaluates the success of coordination of care by looking at the:  

  • exchange of information between behavioral health care and medical practitioners including a complete history of the member’s current medications.
  • appropriate use of psychotropics and medication assisted treatment (MAT).
  • appropriate diagnosis treatment. 
  • referrals of behavioral health disorders. 
  • treatment access according to regulatory standards.
  • follow-up care for members with coexisting medical and behavioral health disorders. 
  • primary or secondary prevention and the special needs of members with severe and persistent mental illness.  

 

Behavioral Health Screening Tools   

Physicians can be the members’ first contact when in need of behavioral health services and/or medications. Members tend to share symptoms, concerns, issues, and other needs with their PCPs rather than or before considering professional behavioral health services. Using behavioral health screening tools can help determine a diagnosis and related complications. The Behavioral Health section of Clinical Corner on our website includes screening tools that can quickly be used with a member via telephone, in person, email, or telemedicine. Members do not need a referral from their PCP to access behavioral health services; however, if you refer a member to one of our behavioral health services programs, please follow up to coordinate care. 

 

Collaborative activities 

EmblemHealth continually conducts activities to improve behavioral health and general medical care, including collaboration with behavioral health practitioners. These include: 

Practitioners’ opportunities for collaboration, continuity, and coordination of care: 

  • Improve the process for members to authorize sharing of behavioral health information. 
  • Implement primary care guidelines for assessing, treating, and referring common behavioral problems. 
  • Increase non-behavioral health care practitioner satisfaction with feedback from behavioral health care practitioners. 
  • Improve procedures for treating hospitalized members with coexisting medical and behavioral health conditions. 
  • Improve management of elderly members with indications of depression and multiple behavioral health care medications. 
  • Educate primary care practitioners about appropriate indications for referring patients with hyperactivity disorder, substance use disorders, or depression to behavioral health care specialists.
  • Facilitate communication between a medical practitioner and the behavioral health care practitioner who is treating the medical practitioner’s patient. 
  • Implement a prevention program for behavioral disorders commonly managed in the primary care setting. 

  

EmblemHealth promotes:   

  • Exchange of information between behavioral health care and medical practitioners. 
  • Appropriate diagnosis, treatment, and referral of behavioral health disorders commonly seen in primary care. 
  • Appropriate use of psychotropic medications. 
  • Oversight of access to treatment and proactive follow-up for members with coexisting medical and behavioral disorders. 
  • Preventive behavioral health care program implementation in both primary and secondary settings. 
  • Accommodations to be made for the special needs of our members with severe and persistent mental illness. 

  

Confidentiality for domestic violence or endangered victims 

Please let your affected patients know they are entitled to these privacy protections: 

  • Group policy members may ask us to enforce an order of protection against the policyholder or other person. We will not disclose their address or telephone number for the duration of the order. 
  • We will accommodate any reasonable request for a covered individual to receive communications of claim-related information by an alternative means or at an alternative location. The member must give us a valid order of protection or let us know he/she is a victim of domestic violence and will be in danger by the disclosure of certain information. 

 

If you think a patient is at risk, please let them know there are organizations ready to help. For a listing of domestic violence hotlines by county, go to the NYS Coalition Against Domestic Violence website: New York State Domestic Violence Programs County Listing. EmblemHealth’s Neighborhood Care sites are also available to assist. You can find additional information on our Domestic Violence Guidelines page. 

 

Required training for mental health & substance abuse (MHSA) providers

The New York State Office of Mental Health (OMH), the Office of Alcoholism and Substance Abuse Services (OASAS), and the New York State Department of Health (NYSDOH) require EmblemHealth’s behavioral health providers to complete State-approved cultural competence training on an annual basis. To satisfy this requirement, providers must complete one of these two programs:

  1. OASAS-approved training. To access a list of OASAS-approved trainers, see the NYS OASAS Training Catalog.
  2. Two Uniform Network Provider Training modules. To access these training modules, visit  the Center for Practice Innovations (CPI) Learning Community.
     

More educational materials

OMH also offers a host of educational materials on its website for behavioral health providers.
 

Children’s Medicaid Health and Behavioral Health System Transformation

The Community Technical Assistance Center of New York (CTAC) offers a collection of training resources around the Children's System Transformation. This includes the transition to Medicaid Managed Care, the new Children and Family Treatment and Support Services, and the aligned Home and Community Based Services. These materials are intended to help prepare new NYS Medicaid Children’s providers for the transition to Medicaid Managed Care. Materials can also be found on the CTAC website.

Claims Corner

Claims Corner

The Claims Corner section of our provider website is part of the EmblemHealth Provider Manual and houses Administrative Guidelines described in our participation agreements. Be sure to check the Claims Corner section of our provider website frequently for the latest updates.   

We created new pages in Claims Corner called Payment Integrity Policies and Reimbursement Policies. These pages have sortable and searchable tables to make information easier to find. As we add policies, we will remove or archive the old postings on the other Claims Corner pages as appropriate. We changed some policy titles to improve sorting results. We also introduced Archive sections to house information that has been replaced or only applies to a prior date of service. We are tagging the older items “Expired” to help you differentiate current vs. prior policy.

Payment Integrity Policies and Audits

New Policies

This year we introduced two formalized payment integrity polices for:

  • Pre/Post Claims Payment Reviews
  • Routine Supplies & Services – Not Separately Reimbursable in the Inpatient Hospital Setting

Outpatient APC Audits

As of Aug. 1, 2021, we added outpatient APC audits to our payment integrity correct coding evaluations. We contracted with Optum to perform these audits on our behalf. Notification via letters, their audit findings, and instructions on how to appeal their determinations are sent directly from Optum.

 

Enhanced Clinical Editing Processes

As of Sept. 1, 2021, EmblemHealth expanded our partnership with Cotiviti, Inc. for periodic post-payment reviews for Retrospective Accuracy datamining (RA) and Clinical Claim Validation DRG review (CCV). These are the same/similar reviews that are currently being conducted by Optum on behalf of EmblemHealth.

 

Reimbursement Policies  

We follow the correct coding rules established by the Centers for Disease Control, American Medical Association, National Uniform Billing Committee, and Centers for Medicare & Medicaid Services for both professional and facility claims. Below is a summary of the substantive updates posted since December 2020, including new policies that will go into effect in 2022:

 

New Reimbursement Policies

  • Coding Edit Rules (new for facility claims and new edits for 2022)
  • Co-Surgeon/Team Surgeon – Modifiers 62/66
  • Definitive Drug Testing (Commercial & Medicaid - limits and exclusions enforcement starts in 2022) 
  • E/M Supplemental Reimbursement Policy 2021 Update
  • HCPCS and CPT Coding Requirements for Outpatient Claims (Commercial)
  • Intraoperative Neurophysiology Monitoring (IONM) (Commercial, Medicare, and Medicaid - New for March 2022)
  • Modifier JW – Drug and Biologicals
  • National Drug Code (NDC) Requirements for Drug Claims
  • No Cost/Reduced Cost Drugs, Implants & Devices (New for 2022)
  • Operating Microscope (Commercial)
  • Preventive Medicine and Screenings (New for 2022)
  • Prolonged Services (Commercial and Medicare)

 

Revised Reimbursement Policies

  • Allergy Testing Immunotherapy
  • COVID-19 Vaccine and Monoclonal Antibody Infusions Reimbursement Policy
  • Modifier PO/PN Guidelines for Clinic Services (G0463)
  • Modifier Reference Policy (Commercial)
  • Never Events/Adverse Events & Serious Reportable Events (Commercial)
  • Outpatient Imaging Self-Referral Reimbursement Policy 
  • Preventive Health Services (Commercial)
  • Preventive Health Services (Medicare)

    

NPI & Taxonomy Codes 

As of Oct. 2021, claims submitted for our Medicaid line of business are being returned to providers as "unclean claims" if the required Taxonomy Code(s) is missing.

 

Sign into your Provider/Practice Profile to make sure you have the right National Provider Identifier (NPI) and Taxonomy Code(s) on file. Using an incorrect code can result in denied claims. Federal law mandates that health care practitioners use their unique, 10-digit NPI when submitting standard electronic health care transactions, such as claims. The absence of taxonomy codes may result in incorrect payments or the inability of your patients to fill their prescription. 

 

EmblemHealth Risk Adjustment Program

EmblemHealth continues to partner with Pulse8™ to promote risk adjustment education and gap closure efforts for our New York State of Health (NYSOH) Marketplace, Medicare HMO, and Medicaid members. The process of risk adjustment relies on providers’ accurate medical record documentation and claims coding to capture the complete health status of each patient. To help you do this, Pulse8 offers free, 60-minute monthly webinars that are followed by a question-and-answer period. We encourage you and your staff to participate. Learn more about Pulse8 and how it can help your practice. You may register for Pulse8’s monthly webinars through the secure provider portal or on our website.

 

Also, you can learn more about the Pulse8 Collabor8 risk adjustment program by clicking on the link below:


The 2021 EmblemHealth Risk Adjustment Program for Primary Care Practitioners (PCPs) is Underway (January 1, 2021 through December 31, 2021).

 

Timely Filing Reminder 

The EmblemHealth timely filing time frame is 120 days from the date of service, unless EmblemHealth is the secondary payor or the participation agreement states an alternative time frame to be applied. See the EmblemHealth Provider Manual for full policy. 

 

Free Electronic Funds Program 

ECHO Health, Inc. facilitates claims payments for EmblemHealth. Through ECHO, you can receive direct deposits to your bank account(s) (known as electronic funds transfer (EFT)) and view or download your remittances online (known as electronic remittance advantage (ERA)). Electronic transactions are fast, convenient, and reduce the risk of lost or stolen payments. This solution is free and allows you to reduce payment processing costs and improve cash flow. Visit ECHO, click on the “Click Here” button, and follow the instructions to enroll.

Clinical Corner

Clinical Corner

The Clinical Corner section of the EmblemHealth provider website is part of the EmblemHealth Provider Manual and houses Administrative Guidelines described in our participation agreements. This is where you will find preauthorization rules, medical policies, care management programs, special utilization management programs, pharmacy information - including formularies, behavioral health and dental information, and more. This is also where you will find current code lists and a Preauthorization Lookup tool.

Be sure to regularly check the Clinical Corner section of our provider website for the latest updates.

Here is a summary of the key updates posted this last year and those anticipated for 2022. 

 

Preauthorization Requirements

You can find all EmblemHealth Preauthorization Lists posted to our website. Changes to the list will be posted to the Preauthorization Rules page, not the News page.

 

Preauthorization List Reductions and Updates for 2022

Good news! Starting Jan. 1, 2022, we are removing 99 codes from the EmblemHealth Preauthorization List, and ConnectiCare’s Preauthorization Requirements for Commercial and Medicare plans. This is part of an ongoing evaluation of our preauthorization lists and an effort to simplify the administrative burden for our providers.

Starting Feb. 1, 2022, five new CPT codes will require preauthorization. These new codes supplement the ones that already require preauthorization for Neurostimulators (63664), Potentially Unproven Services (Q2043), and Cosmetic & Reconstructive Surgery (54416, 54401, 54405). See the full list of CPT Codes and their descriptions on our websites:

EmblemHealth

ConnectiCare

 

Oncology Drug Management Program – 2021 Changes

In 2021, additional codes requiring preauthorization were added to the Oncology Drug Management Program and for Long Term Support Services (S5102, S5130, T1019, T1020, S5160, S5161, S9123, and S9124  for Medicaid members and S9123 and S9124 for Commercial members).

 

New Provider Portal: Preauthorization, Referral, and ER Admission/Notification Transactions

The new Provider Portal makes coordination of care easier. Spend less time on the phone and feeding documents into a fax machine. By using the portal instead of faxes, you help us get started on your reviews sooner since all the requests are legible.

The Preauthorization Check Tool was updated and now returns information for all EmblemHealth and ConnectiCare members.

With the introduction of the new Provider Portal, providers are now able to upload supporting documentation while creating a preauthorization request or afterwards to supplement the request. Providers are asked to only submit the request through the Provider Portal. If, however, a request is submitted over the phone or by fax, do not resend the same request through the portal. Only one request is needed.

TIPS:  Referral transactions require all Users to select both the Referring Provider and the Servicing Provider. Referrals may be submitted up to 30 days after the date of service to support member access to care.

Here are some time-savers for hospital staff:

  • Convenient ER admission and newborn notifications: No more need to call or fax; these transactions can now be done online for all our members. Hospitals can now notify us on the portal – for all EmblemHealth and ConnectiCare managed members – up to 60 days after an admission.
  • Submit Post-Acute Care requests:  You can now make requests on behalf of other providers if you are working on discharge planning requests such as skilled nursing facilities (SNF), long-term acute care health (LTACH), inpatient rehabilitation facility (IRF), home health care (HHC), durable medical equipment (DME), and ambulance services.

If you need help with these transactions or getting access to the portal, see these educational materials (guides and videos), and our Frequently Asked Questions webpage.

 

Referral Policy Updates

In 2021, SOMOS announced that its members will not require referrals to be seen by specialists.

Because of the COVID-19 State of Emergency, our Medicare Members with plans that traditionally require referrals may see specialists without referrals. When this changes, notice will be provided.

The “Do I need a referral?” - A Quick Guide now has updated resources, including a video, to help providers understand when a referral is needed. Please review so you know whether a member needs a referral to see a specialist.

 

Care Management Programs

EmblemHealth and Connecticare’s Care Management programs provide members with a holistic and seamless clinical model throughout their care journey.  We do this by putting members in the driver’s seat. We deliver tailored, high-impact programming that integrates physical and behavioral health and enhances their providers’ work. We provide condition-specific education to reinforce established treatment plans and ensure a thoughtful, member-centric experience to achieve their self-management goals. We can also assist in navigation and coordination support to ensure our members can obtain the necessary care and resources in the right setting.  

  • Care Management Programs: 800-447-0768
  • Healthy Futures Pregnancy Program: 888-447-0337
  • New York State Smoker’s Quitline (tobacco cessation): 866-697-8487
  • ConnectiCare: 800-390-3522

 

Clinical Practice Guidelines

No changes were made in 2021. We encourage our providers to consult EmblemHealth’s and ConnectiCare’s Clinical Practice Guidelines (CPGs) for assistance in the treatment of acute, chronic (e.g. HIV), and behavioral health issues.

 

Mandatory Reporting

To ensure public safety and to track conditions affecting public health, the federal government, New York State and New York City agencies have enacted laws that must be followed by health care professionals. Our network practitioners are required to participate in government reporting procedures and adhere to all rules, regulations, and codes. For a list of government agencies with required reporting, access the Regulatory Mandatory Reporting chapter of our online Provider Manual.

 

Medical Policy Updates

EmblemHealth’s Medical Policies are posted in Clinical Corner in an alphabetized list. Additions and changes are noted after the policy name in the table. Soon, the Pharmacy Medical Policies are going to be moved to their own dedicated page in the Pharmacy section of Clinical Corner.

Below, find the new and revised EmblemHealth medical policies published since December 2020. A similar list can be found in the ConnectiCare section of this annual notice regarding ConnectiCare’s Medical Policies.

EmblemHealth

RETIRED

  • Lung Volume Reduction Surgery
  • Visual Evoked Potential Testing for Pediatric Populations in the Primary Care Setting — Commercial/Medicaid
  • Genetic Testing for Frontotemporal Dementia (FTD)

 

REVISED

  • Abdominoplasty/Panniculectomy
  • Analysis of KRAS Status
  • Artificial Intervertebral Discs
  • Bariatric Surgery
  • Blepharoplasty
  • BRCA 1 and 2 Genetic Testing (Sequence Analysis/Rearrangement)
  • Breast Implants and Reconstruction
  • Breast Reduction Mammoplasty 
  • Capsule Endoscopy 
  • Carrier Screening for Parents or Prospective Parents
  • Cosmetic Surgery Procedures
  • Cryosurgical Ablation for Prostate Cancer
  • Fecal Microbiota Transplant (FMT) For Recurrent Clostridium Difficile Infection
  • Gene Expression Profiling
  • Infertility Services (Commercial)
  • Insulin Delivery Devices and Continuous Glucose Monitoring Systems
  • Lipoprotein Subclassification Testing for Screening, Evaluation and Monitoring of Cardiovascular Disease
  • Lyme Disease Diagnosis and Treatment
  • Neuropsychological Testing
  • Non-Invasive Helicobacter Pylori Testing
  • Noninvasive Prenatal Testing (NIPT) for Fetal Aneuploidy
  • Obstructive Sleep Apnea Diagnosis and Treatment
  • Outpatient Cardiac Rehabilitation
  • Phototherapy, Photochemotherapy and Photodynamic Therapy for Dermatologic Conditions
  • Posterior Tibial Nerve Stimulation for Voiding Dysfunction
  • Recurrent Pregnancy Loss
  • Rhinoplasty
  • Stereotactic Radiosurgery and Proton Beam Therapy
  • Testing for Coronavirus Disease 2019 (COVID-19)
  • Transcatheter Aortic Valve Replacement
  • Transurethral Radiofrequency Micro-Remodeling for Female Stress Urinary Incontinence
  • Vacuum-Assisted Wound Closure
  • Varicose Vein Treatment
  • Virtual Colonoscopy (CT colonography)
  • Visual Electrophysiology Testing
  • Prostatic Urethral Lift (PUL)
  • Gender Affirming/Reassignment Surgery

 

Medical Technologies Database

Our Medical Technologies Database is routinely reviewed to ensure it is current. Dispositions apply to all lines of business unless otherwise indicated. This listing also captures annual procedure coding updates since December 2020.  The database was updated with new 2021 CPT/HCPCS codes, as needed.

 Approved

  • Acessa System (laparoscopic radiofrequency ablation for uterine fibroids) (Added commercial, eff. 9/11/2021, to already-covered Medicare)
  • Eversense Continuous Glucose Monitoring System (Commercial and Medicare)*
  • ExoDx®Prostate IntelliScore (EPI) (Medicare only)
  • FoundationOne Liquid CDx (Commercial and Medicare)
  • Guardant360 LDT (Added Commercial to already-covered Medicare)
  • Immunoglobulin heavy chain locus (IGH@) testing for acute lymphoblastic leukemia (ALL) and lymphoma, B-cell, to guide therapeutic decision making (Commercial, eff. 11/13, added to already-covered Medicare)
  • Medtronic MiniMed 670G and 770G monitoring systems*
  • Myocardial strain imaging (Commercial and Medicaid; added to already-covered Medicare)
  • Nasal endoscopy, surgical; balloon dilation of eustachian tube (E.g., ACCLARENT AERA™ Eustachian Tube Balloon Dilation System, XprESS ENT Dilation System) (Medicare, Medicaid)
  • Per-oral endoscopic myotomy (POEM) for the treatment of swallowing disorders (e.g., achalasia)Prostate cancer antigen 3 gene (PCA 3) screening for prostate cancer (Progensa® PCA3 test [Hologic®]) (Added Commercial to already-covered Medicare)

* Listed in EH Medical Policy, Insulin Delivery Devices and Continuous Glucose Monitoring Systems

 

Rejected

  • Boston Heart Cholesterol Balance® Test
  • Cala Trio™ electrical stimulation of the external upper limb and peripheral nerves of the wrist for essential tremor
  • Guardant Reveal™
  • Monarch External Trigeminal Nerve Stimulation [eTNS] System for pediatric attention deficit disorder (ADHD)
  • PIGF Preeclampsia Screen (PerkinElmer Genetics)
  • PreTRM® (Sera Prognostics)
  • PrecisionBlood™ (San Diego Blood Bank)
  • Patient Specific Talus Spacer 3D-printed talus implant

ConnectiCare

    

ConnectiCare in 2022 & What You May Have Missed in 2021

Many EmblemHealth and ConnectiCare members have plans which give them access to providers in both organizations. See the 2022 Summary of Companies, Lines of Business, Networks, and Benefit Plans to see which plans and networks offer reciprocity, details on PCP and referral requirements, out-of-network coverage, copays, and maximum out-of-pocket limits.

Sample ConnectiCare member ID cards may be found in the EmblemHealth Provider Manual.

To see changes to ConnectiCare’s benefit plans and delivery system that could affect EmblemHealth providers treating ConnectiCare members,

 

Dental Network Changing from DentaQuest to Healthplex in 2022

Our dental partner will be changing in 2022 from DentaQuest to Healthplex. Members who need dental care should be directed to our Find a Doctor directory. If additional assistance is needed, please contact Healthplex at 888-468-2183, Monday to Friday from 8 a.m. to 5 p.m.

 

ConnectiCare to Offer a New Medicare Plan in 2022

ConnectiCare Choice Dual Vista (HMO D-SNP) is a special needs plan for members with full Medicaid and Medicare (Part A and Part B services) coverage that also includes:

  • over-the-counter pharmacy benefits
  • dental
  • vision
  • fitness
  • hearing benefits

Providers will need to coordinate the payment for covered services with Connecticut’s Medicaid program and cannot balance bill members for any services without prior written notice. These members will not have access to EmblemHealth providers.

 

Headlines You May Have Missed

Administrative

Members & Benefits

Utilization Management

COVID-19

Pharmacy

Medical Policy Updates

ConnectiCare’s Medical Policies are posted on the Medical Coverage Criteria page. At the top of the page, select Commercial or Medicare to see the applicable policies. Below, find the new and revised medical policies published since December 2020:

NEW

  • Cortical Stimulation for Epilepsy (NeuroPace®)

REVISED

  • Blepharoplasty
  • Breast Implants and Reconstruction
  • Breast Reduction Mammoplasty – Medical criteria used by ConnectiCare have been retired in favor of EmblemHealth’s criteria.
  • Cryosurgical Ablation for Prostate Cancer
  • Electrophysiology Testing
  • Experimental, Investigational or Unproven Services Medical Necessity Guidelines
  • Lab/Venipuncture Policy
  • Obstructive Sleep Apnea Diagnosis and Treatment
  • Transcatheter Aortic Valve Replacement
  • Visual
  • Non-Invasive H Pylori Testing (Commercial)
  • Rhinoplasty
  • Vertical Expandable Prosthetic Titanium Rib (VEPTR) (Commercial)
  • Visual Electrophysiology Testing
  • Vitamin D Deficiency Testing (Commercial)

RETIRED

  • Lung Volume Reduction Surgery (Commercial)
  • Visual Evoked Potential Testing for Pediatric Populations in the Primary Care Setting (Commercial)

Payment Integrity Policies and Audits

The Payment Integrity Administrative Policy: Pre/Post Pay Claim Reviews criteria was formalized in policy format effective Aug. 1, 2021. We routinely evaluate claims for coding, billing accuracy, and appropriateness. Providers are required to supply requested supporting information such as itemized bills and medical records. It is the billing provider’s responsibility to ensure their responses are both prompt and complete. Note: Neither additional records nor amended records will be accepted once an audit review is complete.

In addition, we added outpatient APC audits to our payment integrity correct coding evaluations effective Aug. 1, 2021. We are contracted with Optum to perform these audits on our behalf. Notification via letters, their audit findings, and instructions on how to appeal their determinations will be coming directly from Optum. 

Reimbursement Policies

We follow the correct coding rules established by the Centers for Disease Control and Prevention, American Medical Association, National Uniform Billing Committee, and Centers for Medicare & Medicaid Services for both professional and facility claims. Below is a summary of the substantive updates posted since December 2020 including new policies that will go into effect in 2022:

New Reimbursement Policies

  • Allergy Testing Immunotherapy (New for March 2022)
  • Co-Surgeon/Team Surgeon – Modifiers 62/66
  • Discontinued Procedures
  • E/M Supplemental Reimbursement Policy 2021 Update
  • Intraoperative Neurophysiology Monitoring (IONM) (Commercial and Medicare - New for March 2022)
  • Modifier JW – Drug and Biologicals
  • Modifier PO/PN Guidelines for Clinic Services (G0463)
  • National Drug Code (NDC) Requirements for Drug Claims
  • Never Events/Adverse Events & Serious Reportable Events (Commercial)
  • No Cost/Reduced Cost Drugs, Implants & Devices (New for 2022)
  • Operating Microscope (Commercial)
  • Preventive Medicine and Screenings (New for 2022)
  • Prolonged Services (Commercial and Medicare)
  • Split Surgical- Modifiers 54/55/56
  • Team Surgery Policy (Modifier 66)

Revised Reimbursement Policies

  • Ambulatory Surgery Groupers (Commercial)
  • Assistant at Surgery
  • Claim Coding Edits
  • COVID-19 Vaccine and Monoclonal Antibody Infusions Reimbursement Policy
  • Experimental, Investigational or Unproven Services (Commercial)
  • Experimental, Investigational or Unproven Services (Medicare)
  • Modifier Reference Policy (Commercial)

Learning Online: Required Training and Educational Opportunities for Medical Providers

The Learning Online section of our provider website is filled with required and recommended learning opportunities. 

Here is a sampling of what you can find there: 

  • Required Training for EmblemHealth Practitioners, Providers, and Vendors - Special Needs Plan (SNP) Model of Care (MOC) training for providers in the VIP Bold Network and Network Access Network. 

  • Required Medicare Training on Fraud, Waste, and Abuse

  • Cultural Competency Continuing Education and Resources   

  • Live Seminars and Webinars for Providers 

  • Health Literacy 

  • Free Continuing Medical Education (CME) Activities Sponsored by Pri-Med  

  • HIV/AIDS Education 

 

Free Pulse8 Webinars for Patient Management and ICD-10 Coding

Pulse8 offers free webinars for patient management and ICD-10 coding. To register, go to pulse8.zoom.us and select the session that interests you. See the full schedule for 2022.

If you have questions, or would like to set up a private session for your practice, please email ProviderEngagement@Pulse8.com or call their Customer Support team at 410-928-4218 ext 7. Their hours are 8 a.m. to 8 p.m., Monday through Friday.

Learn more about the Pulse8 Collabor8 risk adjustment program.

 

HIV/AIDS and Sexually Transmitted Diseases

Pri-Med offers courses such as “HIV update for the non-ID specialist: What every clinician needs to know” and “Pre-exposure prophylaxis for HIV Infection.” Just search for “HIV” to find them. You can manage your learning, track credits online, and complete activities at your own pace. 

  

 The New York State Department of Health, AIDS Institute has lead responsibility for coordinating state programs, services, and activities relating to HIV/AIDS, sexually transmitted diseases (STDs), and hepatitis C. For information on programs, initiatives and services, visit the AIDS Institute for training and resources to help your patients. 

  

To refer a patient to the EmblemHealth HIV Case Management program, please call or have the member call 800-447-0768. 

Pharmacy

2022 Formularies

To see announcements of formulary changes, see EmblemHealth’s Formulary Updates webpage. To determine whether a specific drug is covered by a member’s health plan, use the applicable Formulary search:

 

Home Infusion Utilization Management

On Oct. 1, 2021, Care Continuum (CCUM), an Express Scripts company, began performing home infusion utilization management services for all EmblemHealth and ConnectiCare members.

 

New Cancer Drugs Require Preauthorization

As of Aug. 15, 2021, additional oncology-related chemotherapeutic drugs and supportive agents require preauthorization when delivered in the physician’s office, outpatient hospital, or ambulatory setting. See our Frequently Asked Questions: EmblemHealth Oncology Drug Management to determine where to submit the preauthorization request.

 

Pharmacy Billing for EmblemHealth Dual-Eligible Members

Although the Centers for Medicare & Medicaid Services (CMS) prohibits providers from requesting payment from dual-eligible and QMB members, pharmacies can receive additional payment if they balance bill all applicable Part B items to New York State’s eMedNY program on their members' behalf. See the Pharmacy Balance Billing guide for instructions.

 

Medicare Pharmacy Networks Aligned to Benefits

Our Express Scripts, Inc. pharmacy networks are aligned with the corresponding prescription drug benefits and include preferred pharmacy cost-sharing as follows:

  • Express Scripts Broad Performance Network: VIP Dual SNP plan members, Group Prescription Drug Plan (PDP) members and other plan members without preferred pharmacy drug benefits will access this network.
  • Express Scripts Medicare Preferred Value Network: Most VIP members will access this network.
    • Costco
    • Rite Aid
    • ShopRite
    • Walgreens
    • Duane Reade
    • Walmart
    • CVS
    • Target
    • Talk to members about the importance of taking their medications on time as prescribed.
    • Remind members to track their refills and make an appointment for a new prescription before they run out.
    • Educate members on the side effects of the medications and how to treat them.
    • Help identify and resolve barriers to members not taking their medication as prescribed.
    • Consider prescribing 90-day supply prescriptions for maintenance medications.
    • Consider prescribing generic drugs or less-expensive brand-name drugs on the member’s formulary if cost is a barrier.
    • Talk to the member about potential state drug assistance programs or pharmaceutical prescription assistance programs that may be able to help with the cost of the medication.
    • Educate members on pharmacy-based adherence tools that may help:
      • Medication synchronization (limit the member’s trip to the pharmacy for medications).
      • Compliance packing or blister packs.
      • Auto refills.
    • Encourage members to leverage available technologies (medication reminder apps on your phone or tablet, like the Express Scripts mobile app).

    • Preferred pharmacies help members save on prescription drugs and improve medication adherence, so we ask that you remind members to use a preferred pharmacy when you can.

    Some of the preferred pharmacies in New York include:

    Standard pharmacies that participate in the Preferred Value Network but only offer standard cost-sharing include:

    Pharmacy locator links are available on our website to help you and your members find a nearby participating pharmacy.

    Help Members Stick with Their Medication Regimen by Using Our Mail Order

    Pharmacy Taking medications as prescribed (medication adherence) is important for treating and controlling chronic conditions. Doctors play an important role in helping members stay adherent. Here are some steps as a doctor you can take to help members remain adherent:

    Starting Jan. 1, 2022, many of our plans will offer generic drugs (Tier 1 and Tier 2) for $0 copay for members who get their refills through Express Scripts Preferred Mail Order pharmacy. Please help your members stay adherent and save on their prescription drugs by recommending members switch to preferred mail order:

    Express Scripts Home Delivery Service PO Box 66577 St. Louis, MO 63166-6577

    or Call: 877-866-5828 (TTY: 711)

     

    Pharmacy Billing for EmblemHealth Dual-Eligible Members

    Both Federal and State laws protect dual eligibles from being balance billed. For more information about coordinating benefits with Medicaid for pharmacy providers, see the Pharmacy Balance Billing guide for instructions.

Your Resources

For a list of frequently used phone numbers, addresses, and websites, see the Directory Chapter of the EmblemHealth Provider Manual.

 

How Do I?

You can save time by checking Provider Help and Support page's compilation of frequently asked questions and answers before contacting Customer Service. 

 

Provider Portal

Take advantage of our new provider portal. You can check member eligibility and benefits, review claims status, update your practice information, create a referral, request preauthorization, and more. Plus, no more signing in and out of our sites. You can now see information and process transactions for all of our members with one User ID!

Our new Provider Portal is designed to be simple and intuitive. Should you need help, see the How do I use the Provider Portal? Tab of the Provider Help and Support page for key things you should know.  If you first need to set up an account, or have a question about a transaction, see our provider portal frequently asked questions webpage to address the most common issues our Provider Customer Service team has been receiving.

To help you with the online transactions, we have posted a series of videos and user guides to help you step by step through each one.

 

Provider Manual

The online Provider Manual is an extension of your contract with us. It has information about your administrative responsibilities, contractual and regulatory obligations, and best practices for helping members navigate our delivery systems. Revisions are made as policies are renewed, new programs are introduced, and rules change.

 

EmblemHealth Neighborhood Care

EmblemHealth Neighborhood Care provides in-person customer support, access to community resources, and programming to help the community learn healthy behaviors. Members and non-members alike can visit Neighborhood Care and take advantage of our classes, tools, and face-to-face support. The health and wellness classes support the different dimensions of wellness, including physical, financial, social, and emotional. Neighborhood Care does not provide medical services. Instead, our role is to help practitioners manage patient care by supporting the practitioner-patient relationship.

 

Member Materials

This page offers materials you can give your members in support of your care plans. 

 

Provider Toolkit

The Provider Toolkit has guides and quick references to help with the administration of our plans. The Toolkit is where we house Welcome materials for new providers.  

 

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