Updates to Self-Funded Plan Timely Filing Limits
Starting Sept. 1, 2023, providers are required to submit claims for EmblemHealth members who are part of the Local 389 Health and Welfare Fund within 90 days of the date of service. This time frame applies to new in- and out-of-network medical claims (professional, hospital, and other facility claims). See full Claims Submission – Timely Filing requirements.
Laboratory Benefit Management Program
EmblemHealth and ConnectiCare implemented a Laboratory Benefit Management (LBM) program in collaboration with Avalon Healthcare Solutions. The Laboratory Benefit Management Payment Integrity Policy details the program components, including impacted laboratory services, tests, and procedures. It also includes a section of anticipated frequently asked questions (FAQs). In addition, we have posted training guides to help you understand how this program helps us process laboratory claims with greater accuracy and consistency.
The program’s reimbursement policies are on our websites and are available for your review. If you receive a claim denial, the message will provide this website address, bit.ly/Our-RP, as a shortcut to the policies. Look for the applicable test to see why the claim was denied. It will be tagged “(LBM).” The same policies may be found on both of our sites at the following links:
To reflect the end of the COVID-19 Public Health Emergency, we replaced the COVID-19 Testing Reimbursement Policy with this new one: Coronavirus Testing in the Outpatient Setting (LBM). We also updated the Payment Integrity Policy for the Laboratory Benefit Management Program to add Coronavirus Testing in the Outpatient Setting (LBM) to the Reimbursement Policies table.
EmblemHealth Risk Adjustment Program for Primary Care Providers
Together, EmblemHealth and Pulse8™ promote risk adjustment education and gap closure efforts for our New York State of Health (NYSOH) Marketplace, Medicare HMO, and Medicaid members. See the Pulse8 Risk Adjustment frequently asked questions.
Primary care providers (PCPs) are encouraged to take advantage of these additional compensation opportunities and Pulse8’s free monthly webinars. You may use telehealth/virtual care to close gaps in care.
CPT and HCPCS Billing Guidelines
While EmblemHealth recognizes some HCPCS codes, they are not always consistent with those recognized by Medicare. Although exceptions may apply, such as for drug testing, unless otherwise specified, CPT codes should be billed even when there is a corresponding HCPCS code.
Whenever possible, convert HCPCS code(s) to the applicable CPT code(s) before you submit your claims to EmblemHealth or ConnectiCare. When a more appropriate code is required, a service may be denied, giving the provider an opportunity to submit a more appropriate code. See CPT and HCPCS Billing Guidelines.
Daily Maximum Units
EmblemHealth and ConnectiCare follow the Centers for Medicare & Medicaid Services (CMS) guidelines. We will not reimburse CPT/HCPCS codes with a Medically Unlikely Edits (MUE) value of “0” (zero). This applies to all EmblemHealth and ConnectiCare Medicare Advantage plans. For Medicare non-covered services that are covered by our Commercial plans, EmblemHealth and ConnectiCare have established Maximum Daily Frequency (MDF) exceptions. These exceptions are listed in our Daily Maximum Units reimbursement policy.
NPI & Taxonomy Codes
Sign in to your Provider/Practice Profile to make sure you have the right National Provider Identifier (NPI) and Taxonomy Code(s) on file.
No-Cost Electronic Funds Program
ECHO Health, Inc. facilitates claims payments for EmblemHealth. Through ECHO, you can, at no cost, 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 advice (ERA)). Visit ECHO, click the “Click Here” button, and follow the instructions to enroll.
