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Starting July 15, 2024, we will be updating our Site of Service Medical Policy – Infusions and Injectables to add 170 medications and remove the age restrictions so the policy will apply to all commercial members, not just those over the age of 21. We are modifying our protocols to ensure that injectable and infusion medications are administered at the most clinically appropriate site of care.

These drugs already require preauthorization. However, they may no longer be covered when administered in a hospital setting and may require administration in a member’s home or other outpatient location. We are making this change to expand the successes we are seeing in lowering member’s out of pocket costs and providing convenient access to care for ongoing maintenance infusion services. See full announcement and code list.

The 2024 Quality Incentive Program is underway for eligible EmblemHealth and ConnectiCare providers. A new brochure highlights this provider network program to show how eligible providers can be rewarded for delivering better health outcomes. The brochure outlines incentive measure opportunities and targets and explains how providers can be eligible to participate. Click the appropriate link to view this brochure.

EmblemHealth  |  ConnectiCare

Home Care Extensions

We have good news for our Home Care Agencies!

Caring for patients who are recovering from surgeries and illnesses means that the predicted care needs don’t always match the patients’ actual needs. We understand that you need a way to request an extension if you discover a patient needs more assistance than allotted for in the preauthorization.

We heard your concerns. Based on your feedback, we updated our systems so they won’t reject your preauthorization requests for extensions.

Please start using the provider portal now for all new extension requests.

Reminder: Fax Lines To Be Disconnected May 2024

Starting May 1, 2024, we will disconnect the fax lines currently in use for preauthorization requests and concurrent reviews. Please use the provider portal to submit your requests and supporting documentation. See original announcements (EmblemHealth | ConnectiCare) sent in December 2023.  We also recently sent an email. 

Serving our members requires knowing their needs, including the languages they speak. We serve a diverse membership whose top languages include English, Spanish, Chinese, and Italian. As visuals often send a powerful message, we created maps of our EmblemHealth and ConnectiCare core service areas to get a county-level view of these languages. We encourage you to look for your county and see how our members communicate. Data used for these maps is representative of active membership at the end of January 2024.

EmblemHealth and ConnectiCare partner with Episource to conduct Medicare and NY State of Health (NYSOH)/Access Health CT chart reviews required by the Centers for Medicare & Medicaid Services (CMS).

The purpose of the chart review is to capture proper ICD-10 coding and identify any areas of improvement. Instances of improper coding will be identified during the review and shared with you. Proper coding helps us better serve our members.

If you receive a medical record request from Episource, please follow the instructions and send the requested documentation directly to Episource as required by your participating provider agreement. Medical record requests will occur throughout the year. We appreciate your prompt response to all Episource medical record requests.