Office Visit

Oral PrEP, a medication used for HIV-negative individuals at risk of exposure, is up to 99% effective in preventing HIV acquisition from sex and at least 74% effective from injection drug use. When a patient needs a PrEP prescription, consider which option will save them money and support their adherence to their medication regimen.

Our members may be eligible for a zero-dollar copay. See our flyer for zero-dollar copay criteria and a comparison of the FDA-approved oral treatment options for PrEP: Descovy^® and Truvada^®.

We ask our New York providers to consider registering for inclusion in the New York State Department of Health PrEP Prescribers directory.  

Here are a few resources for you and your patients: 

• CDC HIV Resources.
• NYSDOH Online Resources for Education, Information, and Services.
• HIV/AIDS Services in Connecticut.

To avoid claims denial and the need to submit corrected claims, please make note of the following when billing telehealth and virtual care services in 2025. To maintain payment parity between in-person and telehealth visits for services rendered in 2025, continue to use the existing office visit procedure codes with appropriate modifiers and place of service codes.

Since Current Procedural Terminology (CPT) code G2012 has been retired, CPT Code 98016 may be used in its place for brief virtual check-in visits with established patients. Otherwise, EmblemHealth and ConnectiCare are not accepting the new telehealth codes for 2025. See our Telehealth/Virtual Care Services reimbursement policy.

We have a new online member resource you can share with your patients to help raise awareness of yearly preventive vaccines.

As you know, children, adults over 65, and people with chronic conditions such as asthma, are at a higher risk of flu complications. We encourage vaccination among this population and for people who are pregnant or have recently had a baby.

As our partner in our members’ health care, please talk to your patients about the importance of vaccinations. To see a summary of the various seasonal vaccines we recommend and basic coverage information, visit EmblemHealth | ConnectiCare. 

In recognition of Colorectal Cancer Awareness Month, we encourage you to take this opportunity to teach patients about the importance of prevention and treatment.

Colorectal cancer screening should begin at age 45 for those with average risk and continue until age 75. EmblemHealth covers colorectal cancer screening for members with $0 cost-share.

Available testing options:

• Guaiac-based fecal occult blood test (gFOBT) every year.
• Fecal immunochemical test (FIT) every year.
• Stool DNA-FIT test every one or three years.
• Flexible sigmoidoscopy every five years.
• Flexible sigmoidoscopy every 10 years plus FIT every year.
• Colonoscopy every 10 years.

The following resources can help you educate patients:

• Colorectal Cancer Screening: Patient Version (National Institute of Health).
• Colorectal Cancer Screenings Tests (CDC).
• Colorectal Cancer Screening Patient Poster (American Society for Gastrointestinal Endoscopy).
• Resources for National Colorectal Cancer Awareness (American Society for Gastrointestinal Endoscopy).

National Kidney Month is the perfect opportunity to teach patients about the importance of screening to help prevent kidney disease. It’s especially important for patients with chronic conditions such as diabetes and high blood pressure who are at high risk for developing kidney disease.
Here are some ways to help your patients who may be unfamiliar with kidney disease or unaware of ways to maintain kidney health.

• Teach patients about the importance of diet, exercise, nutrition, weight control, and sleep.
• Encourage patients to manage their blood sugar. People with diabetes, or a condition that causes high blood sugar, may develop into kidney damage.
• Encourage patients to monitor blood pressure. High blood pressure can cause kidney damage. If high blood pressure occurs with other health issues like diabetes, heart disease, or high cholesterol, the impact on the body can be significant.

Actions for you to take to help your patients and be compliant with the Quality measure – Kidney Evaluation for Patients With Diabetes (KED):

• Create a treatment plan for at-risk patients that fits their lifestyle and dietary needs.
• Order a kidney health evaluation annually for all patients with Type 1 or Type 2 diabetes. This evaluation should include BOTH tests:
  • Estimated glomerular filtration rate (eGFR).
  • A urine albumin-creatinine ratio (uACR) identified by either of the following: 
    • Both a Quantitative Urine Albumin test and a Urine Creatinine test with service dates four days or less apart.
    • Urine Albumin Creatinine Ratio test (uACR).

Here are some resources you can share with your patients:

• National Kidney Month (National Kidney Foundation).
• Kidney Professionals (National Kidney Foundation).
• Kidney Disease (National Institute of Diabetes and Digestive and Kidney Diseases).
• Quality Improvement (EmblemHealth).

EmblemHealth and ConnectiCare update their claims processing systems based on code updates received from American Medical Association (AMA), CPT^® and 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 process will 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.

EmblemHealth Preauthorization List: See list for code changes and applicable effective dates.

 See revision histories for the updates to the following lists:

• GHI PPO City of New York Preauthorization List.
• ConnectiCare Commercial Preauthorization List.
• ConnectiCare Medicare Preauthorization List.
• EmblemHealth/ConnectiCare Home Infusion Therapy Drug Preauthorization List.
• The Pharmacy Medical Preauthorization Lists for EmblemHealth and ConnectiCare.

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 use our Referral Form to send your patients to us. See ConnectiCare Centers’ website for their locations and events.

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 EmblemHealth and 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 EmblemHealth as an eligible plan to access your CAQH 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 set up the expected time frames for appointment availability, appointment wait times, and after hours coverage. You can find the EmblemHealth Provider Manual in the top navigation menu of our provider website, emblemhealth.com/providers.

Here are links to the most recent updates:

• Directory Chapter
• Provider Networks and Member Benefit Plans
• Utilization and Care Management