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As we welcome 2025, we want to make sure our providers have a strong understanding of the plans we offer our members. Please review the following key resources we’ve prepared to give you and your patients an easier time navigating our plans.

First, our new 2025 Summary of Companies, Lines of Business, Networks, and Benefit Plans is a vital resource for helping your practice see which plans we are offering in 2025, and whether they are linked to a network or line of business for which you are contracted. We have also updated the following pages to give you the most updated information about our plans:

• EmblemHealth Medicare Advantage Plans.
• EmblemHealth Commercial Networks and Benefit Plans.

For our Connecticut providers, we updated the Commercial Networks and Benefit Plans and the Medicare Advantage pages of our website.

We look forward to partnering with you in 2025 as you deliver care to our members.

The $15 copayment for the EmblemHealth-GHI portion of the Senior Care Plan for City of New York (CNY) retirees resumed Jan. 1, 2025. As part of the benefit plan collectively bargained between the City and its unions, Senior Care members are now required to pay a $15 copay each time they use the health services listed below. Copays are limited to one copay per provider per date of service.

If you are a provider delivering the following services for Senior Care Plan members, you will need to collect the required $15 copay:

• Primary care provider (PCP) office visits. 
• Specialist office visits.                                                       
• Allergy testing/injections.                                                   
• X-rays.                                           
• Laboratory tests.  
• Complex diagnostic and radiology services.                     
• Radiation therapy.                                                             
• Urgent care services.                                                        
• Emergency care (professional component).                     
• Mental health care (outpatient).                            
• Substance use disorder services (outpatient).      
• Physical, occupational, and speech therapy.        
• Cardiac rehabilitation.                                                        
• Pulmonary rehabilitation.                                       
• Chiropractic care.                                                              
• Podiatry care.                                                                    
• Vision care.                                                                      

Please note: Senior Care Plan members are responsible for the annual Medicare Part B deductible and $50 GHI Senior Care deductible.

We are committed to making quality care available to our members. To help you and your billing staff correctly code your claims to include and exclude members from various measures, we are introducing two new resource guides:

• Transitions of Care: Claims coding impacts quality scores. It is just as important to code your claims to exclude patients who do not meet a measure’s criteria as it is to include those who do.

• Advanced Illness and Frailty Exclusions: Strong care coordination is vital for ensuring that patients successfully transition from an inpatient setting back to their home.

Coming Soon! Look for the 2025 versions of other quality guides and resources in a future edition.

Hypertension is a leading risk factor for heart disease and stroke. During February, nationally recognized as American Heart Month, we take time to focus on conditions such as high blood pressure and other diseases and habits that affect heart health.

The American Heart Association recommends statins of moderate or high intensity for adults with clinical atherosclerotic cardiovascular disease to help reduce the risk of heart attack or stroke. See our website for information on statin therapy and more for patients with cardiovascular disease.  You may also  visit the Centers for Disease Control and Prevention for information on lifestyle choices and other ways that can help people can lead a longer, healthier life.

Starting Jan. 1, 2025, we are introducing a new Magnetic Resonance Image Guided High Intensity Focused Ultrasound (MRgFUS) Reimbursement Policy for both EmblemHealth and ConnectiCare

The following reimbursement policies have been updated. If the policy name does not have a company name shown, the policy applies to both EmblemHealth and ConnectiCare.

Laboratory Benefit Management policies are indicated by (LBM) after their names. See their revision histories for effective dates and applicable changes.

• Bundled Services (Commercial and Medicare).
• ConnectiCare Preventive Care Services (Commercial).
• ConnectiCare Preventive Care Services (Medicare).
• ConnectiCare’s Laboratory/Venipuncture.
• Diagnosis of Vaginitis (LBM).
• EmblemHealth Preventive Care Services (Commercial).
• EmblemHealth Preventive Care Services (Medicare).
• Human Immunodeficiency Virus (HIV) (LBM).
• Multiple & Bilateral Surgical Procedures Policy.
• Multiple Diagnostic Imaging Payment Reduction Policy (Commercial).
• Multiple Procedure Reduction Cardiology/Ophthalmology.
• Onychomycosis Testing (LBM).
• Telehealth/Virtual Care Services.

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:

• Jan. 28/30: 2025 Coding Updates: New Year, New Codes!
• Feb. 25/27: The ABCs of Coding for Common Pediatric Conditions

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 45-year-old female living with diabetes, used the coaching services offered to create healthy habits and saw positive results. “My A1C went down and I’m feeling more and more motivated! I’ve been going outside for walks three to four times week. I’m impressing myself!”

To see which of our benefit plans offer WellSpark’s resources, review the 2025 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.

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.