Office Visit

The steps you take to find the status of a grievance or appeal on our provider portal depends on whether you were the person who originally submitted the request.

Instructions for original submitters

If you submitted the original grievance or appeal through the provider portal, the easiest way to find out if a determination has been issued is to follow these steps:

1. Click the user profile icon in your browser’s top right corner. (It looks like a person in a circle. See guides and videos below for pictures.)
2. A drop-down menu will open.
3. Select “My Messages.”
4. Locate the original message from the list.
5. If the Response column shows “Yes,” click on the Message ID to see the response.
6. If the Response column shows “No,” click on the Message ID and use the Follow Up button to request a status.

Non-submitter instructions

If you did not submit the grievance or appeal, you may contact Provider Customer Service for assistance. 

• EmblemHealth: 866-447-9717
• ConnectiCare: Commercial: 860-674-5850; Medicare: 877-224-8230

Guides and videos

For step-by-step instructions on using the Message Center, see these guides and videos on how to search and view messages:

• EmblemHealth: View Guide   View Video    
• ConnectiCare: View Guide   View Video 

To make it easy to see which plans we will be offering in 2025, and whether they are linked to a network or line of business you are contracted for, we recently published the 2025 Summary of Companies, Lines of Business, Networks, and Benefit Plans.

For our Connecticut providers, we updated the Commercial Networks and Benefit Plans and the Medicare Advantage pages of our website that show how the different networks and their associated plans accommodate different members’ needs.

EmblemHealth has provider contracts with Quest Diagnostics, LabCorp, and other laboratories for outpatient lab testing.

Please refer your EmblemHealth members to participating laboratories in accordance with EmblemHealth Policies and Procedures and your Participation Agreement.

A list of participating labs can be found at emblemhealth.com/lablist.

If you do not have an account with Quest Diagnostics or LabCorp, you may establish one by contacting them:

Quest Diagnostics: 866-697-8378

LabCorp: 888-522-2677 or nenewaccounts@labcorp.com

The American Cancer Society estimates that more than 13,000 new cases of invasive cervical cancer will have been diagnosed in the United States in 2024. More than 4,000 women will die from cervical cancer.

There’s no single, simple solution to ending cervical cancer, but the disease is preventable with vaccination and appropriate screening.

January is Cervical Health Awareness Month, so you may find it useful to leverage awareness of this recognition month to foster a conversation with your patients about the importance of screening. 

Cervical Cancer screening is a quality measure and is included in our Quality Measures Resource Guide.* The resource guide provides details of quality measures, descriptions of documentation/coding, best practices, and steps to close care gaps.

Who is included in the measure?

Women 21 – 64 years of age who had a proper screening for cervical cancer in the required time frame.

Actions needed for compliance

Cervical cancer screening for women 21 – 64 years of age, following the required time frame:

Women 21 – 64 years of age: Cervical cytology during the current year or two years prior to the current year (every three years).

Women 30 – 64 years of age: Cervical high-risk human papillomavirus (hrHPV) testing performed during the current year or four years prior to the current year (every five years).

Women 30 – 64 years of age: Cervical cytology/HPV co-testing during the current year or four years prior to the current year (every five years).

Documentation/coding requirements

Documentation of date (month, year) cervical cytology was performed and results or findings.

Use correct billing codes and ensure timely submission of claims:

Cervical cytology CPT: 88141 – 88143, 88147, 88148, 88150, 88152 – 88164 – 88167, 88174, 88175.

HCPCS: G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091.

HPV test CPT: 87624, 87625.

HCPCS: G0476.

Steps for closing care gaps:

1.    Use the Gap in Care report to identify patients to schedule for a wellness visit, if not yet arranged. You can also use the Gap in Care report to identify patients who are not compliant for this measure. Filter for measure name and ‘non-compliant’ using the ‘Compliant Status’ column.

2.    During visit, highlight the importance of early detection, review barriers, and stress importance of yearly screening.

3.    Place reminders in patients’ charts for when next screening is due, and reminder calls for scheduling.

4.    Flag charts of patients after screening is performed to ensure timely follow-up of results and data capture for compliance.

5.    Request to have cervical cytology results sent to you if done at an OB/GYN office.

Learn more about cervical health awareness and prevention and other Quality tips at EmblemHealth.

*The information contained in the Quality Measures Resource Guide was compiled in November 2023 and is subject to change as the sources update their specifications. The 2025 version is coming soon. Measures included in this guide are sourced from the National Committee for Quality Assurance (NCQA) — ncqa.org, Centers for Medicare & Medicaid Services (CMS) — cms.gov, and New York State Department of Health (NYSDOH) — health.ny.gov. NCQA HEDIS^® specifications and New York state Value Set Directory can be viewed at ncqa.org/hedis/measures. Please confirm with your EmblemHealth or ConnectiCare provider network representative that suggested codes are payable per your specific contract.

Effective Jan. 1, 2025, EmblemHealth will introduce a new Laboratory/Venipuncture Reimbursement Policy that is aligned with CMS and Federal Clinical Laboratory Improvement Amendments’ (CLIA) regulations. EmblemHealth will only reimburse you for laboratory services you are certified to perform through the Federal CLIA Laboratory Program. EmblemHealth will consider reimbursement of CLIA waived laboratory tests for its network physicians when performed in their office. CLIA waived laboratory tests are allowed with a CLIA Waiver and do not require a certificate of accreditation or compliance.

Billing tips: All claims billed on a CMS 1500 Health Insurance Claim Form, or its electronic equivalent, must include a valid Federal CLIA Certificate Identification number. If the claim is for a CLIA waived test, the Modifier QW must be used.

The following reimbursement policy has been updated. This policy applies to both EmblemHealth and ConnectiCare. See revision history for effective dates and applicable changes:

• Hospital Readmission Policy.

The following updates are being made to the Lab Benefit Management program. We are introducing a new Serum Testing for Evidence of Mild Traumatic Brain Injury (LBM) policy and are making updates as shown in the revision histories to the following policies: 

• B-Hemolytic Streptococcus Testing (LBM).
• Biochemical Markers of Alzheimer Disease and Dementia (LBM).
• Biomarkers for Myocardial Infarction and Chronic Heart Failure (LBM).
• Bone Turnover Markers Testing (LBM).
• Cardiovascular Disease Risk Assessment (LBM).
• Celiac Disease Testing (LBM).
• Cervical Cancer Screening (LBM).
• Diagnostic Testing of Common Sexually Transmitted Infections (LBM).
• Diagnostic Testing of Influenza (LBM).
• Epithelial Cell Cytology in Breast Cancer Risk Assessment (LBM).
• Fecal Analysis in the Diagnosis of Intestinal Dysbiosis and Fecal Microbiota Transplant Testing (LBM).
• Fecal Calprotectin Testing in Adults (LBM).
• Flow Cytometry (LBM).
• Folate Testing (LBM).
• Gamma-glutamyl Transferase (LBM).
• General Inflammation Testing (LBM).
• Hepatitis Testing (LBM).
• Identification of Microorganisms Using Nucleic Acid Probes (LBM).
• Immunopharmacologic Monitoring of Therapeutic Serum Antibodies (LBM).
• In Vitro Chemoresistance and Chemosensitivity Assays (LBM).
• Lab Testing for the Diagnosis of IBD (LBM).
• Measurement of Thromboxane Metabolites for ASA Resistance (LBM).
• Metabolite Markers of Thiopurines Testing (LBM).
• Nerve Fiber Density Testing (LBM).
• Oral Cancer Screening and Testing (LBM).
• Pancreatic Enzyme Testing for Acute Pancreatitis (LBM).
• Pathogen Panel Testing (LBM).
• Prenatal Screening-Nongenetic (LBM).
• Prostate Biopsy Specimen Analysis (LBM).
• Serum Testing for Hepatic Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease (LBM).
• Serum Tumor Markers for Malignancies (LBM).
• Testing for Alpha-1 Antitrypsin Deficiency (LBM).
• Testing for Diagnosis of Active or Latent Tuberculosis (LBM).
• Testing for Vector-Borne Infections (LBM).
• Thyroid Disease Testing (LBM).
• Urine Culture Testing for Bacteria (LBM).
• Venous Thrombosis Risk Testing (LBM).

Starting Jan. 1, 2025, EmblemHealth is introducing a new Habilitative and Rehabilitative Services Reimbursement Policy that describes how claims for habilitative and rehabilitative services should be reported using the appropriate modifiers. Claim lines submitted for habilitative and rehabilitative services without the appropriate modifier appended will be rejected for incorrect coding.

If you need help navigating our provider portals, please see our videos, quick guides, and Frequently Asked Questions pages:

• EmblemHealth Videos and Guides.
• EmblemHealth Frequently Asked Questions.
• ConnectiCare Videos and Guides.
• ConnectiCare Frequently Asked Questions.

If you still have questions or need additional support, contact Provider Customer Service using the provider portal’s Message Center or live agent chat.

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:

• Dec. 17/19  Narrow It Down: Documentation and Coding for Vascular Disorders.
• Jan. 28/30  2025 Coding Updates: New Year, New Codes!

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.

We recommend that you take advantage of the training opportunities offered by CMS’ Medicare Learning Network and eMedNY. 

WellSpark Health’s broad range of well-being resources are helping our members achieve positive behavioral and lifestyle changes. One member, a 29-year-old male, was encouraged to complete his annual blood work as part of his annual wellness program and found it to be a real eye opener. “I had no idea how much the food I ate was affecting my body. I’m so glad that I was able to learn about this all now, while I’m young enough to reverse the direction I was going before needing medications.”

To see which of our benefit plans offer WellSpark’s resources, review the 2024 Summary of Companies, Lines of Business, Networks & Benefit Plans. We ask that you encourage eligible members to sign in to the member portal to see what is available to them and to take advantage of the support offered.

Learn more about WellSpark resources that may be available to your EmblemHealth and ConnectiCare members:

• EmblemHealth commercial members.
• ConnectiCare commercial members.
• EmblemHealth Medicare members.
• ConnectiCare Medicare members.
• City of New York Gold HMO Preferred plan members.

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.

Starting Dec. 20, 2024, we are adopting daily file feeds from CAQH for non-delegated professional providers’ demographic information based on an NPI and tax ID combination. If changes are needed to your directory information, you should make them in the CAQH application. Changes made in our provider portal will be overwritten with CAQH’s information. There are a few exceptions. See how to communicate data changes with us going forward:

EmblemHealth | ConnectiCare.

Quarterly Directory Listing Validation

We will also have CAQH conduct our quarterly directory validation audits. Please make your staff aware that CAQH may call and empower them to validate your directory and network participation.

The EmblemHealth and ConnectiCare provider manuals are valuable online resources and an extension of your Provider Agreements. You can find the manuals in the top navigation menus of our provider websites, EmblemHealth | ConnectiCare.

The manuals apply to all 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.

Key resources include Access & Availability Standards for EmblemHealth and ConnectiCare which set up the expected time frames for appointment availability, appointment wait times, and after hours coverage.