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July 2024
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Thank you for your enthusiastic use of our provider portal to submit preauthorization requests and clinical review materials. By now you are recognizing the advantages of using the portal for your practice’s transactions.
We are working on more portal improvements. The next release is slated for the fall. You will then see the following changes:
- Preauthorization requests and emergent inpatient admission notifications will be saved as drafts for 96 hours. This will allow the original user, or another affiliated user, time to gather necessary clinical information and documentation.
- A new screen will appear to show users the draft requests and notices that have been submitted. Navigation to the screen will be added to the Take Action section of the home page as well as to the Preauthorization menu.
- Clinical guidelines must be addressed and supporting documents uploaded before a preauthorization request or emergent inpatient admission notification may be submitted.
- We will remove the initial screen that collects supporting documentation. All documents will be attached using the MCG screens.
- There will be improved searching capabilities to identify the requesting and servicing providers.
When patients transition from the hospital back to home, their care coordination can be negatively affected.
Some of the issues include:
- Lapses between inpatient and outpatient providers.
- Intentional and unintentional medication changes; incomplete diagnostic workups.
- Inadequate patient, caregiver, and provider understanding of diagnoses, medication and follow-up needs.
To help improve these outcomes, the Transitions of Care HEDIS® measure is included in our Quality Incentive Program (QIP). You can earn incentives and help your patient have a successful transition from hospital to home.
This measure requires:
- One follow-up visit within 30 days of discharge.
- Discharge medications to be reconciled with outpatient medications in the patient medical record within 30 days of discharge.
Please visit Quality Improvement | EmblemHealth or Quality Improvement | ConnectiCare to learn more about the QIP program from our brochures that provide detailed measure and coding information and helpful tips to ensure you receive credit for providing these services.
Starting Oct. 1, 2024, our current ConnectiCare ED Outpatient Facility E/M Coding Reimbursement Policy will expand to include EmblemHealth’s HMO and PPO (non-City of New York) Commercial, Medicare, and Medicaid plans. This policy will apply to all facilities, including freestanding facilities, that submit emergency department (ED) claims with evaluation and management codes (E/M).
We observed a significant number of EmblemHealth claims submitted with codes that lacked evidence to support the level billed. This change will help EmblemHealth pay claims based on coding that accurately reflects the level of care provided to our members.
To implement the new policy, EmblemHealth, like ConnectiCare, will use the Optum Emergency Department Claim (EDC) Analyzer tool™. The EDC Analyzer tool determines the appropriate E/M coding level based on data such as the patient’s presenting problem, diagnostic services performed during the visit, and associated patient comorbidities. To learn more about the EDC Analyzer tool, please visit EDCAnalyzer.com.
Facilities submitting claims for ED E/M codes may experience adjustments to level 2,3, 4, or 5 E/M codes to reflect an appropriate level E/M code or may receive a denial, based on the reimbursement structure within their EmblemHealth contracts. Facilities may submit an appeal request though our provider portal if they believe a higher-level E/M code is justified.
Starting Oct. 1, 2024, EmblemHealth will expand our current Laboratory Benefit Management (LBM) program with Avalon Healthcare Solutions (Avalon) to our HMO and PPO (non-City of New York) Commercial, Medicare, and Medicaid plans.
Avalon already reviews laboratory services for other EmblemHealth and ConnectiCare members when performed in office, hospital outpatient, and independent laboratory settings reported on claims (post-service and pre-payment).
In support of this program, 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). To provide transparency regarding this program and the review standards that will be used, we have reimbursement policies designated (LBM) that are being updated to reflect the program’s expansion to the EmblemHealth plans indicated above.
If you are not already familiar with this program, we recommend reviewing this Laboratory Benefit Management Program Provider Training Guide.
As you know, children, preteens, and teens have specific vaccination requirements for school or day care. Furthermore, certain immunizations are recommended at specific ages. (See recommendations for ages 7 to 18 and 6 and younger.)
The number of summer pediatric visits is generally very low, so this is a great time to get families in for vaccines, immunizations, and boosters too!
Here are some helpful tips to engage parents and improve immunization rates:
- Review charts for immunization gaps before the scheduled appointment and ensure chart is accurate and thorough.
- Proactively outreach parents to schedule their child’s vaccination appointments.
- Educate your care teams about scheduling visits within the guideline time frames.
- Continue to review immunization records before each appointment (even sick visits) and ensure that records are up to date. This may be a terrific opportunity to catch up on missing immunizations.
- Advise parents on the importance of timely completion of each vaccine series.
Your influence is key in the development, health, and well-being of children.
This measure is based on the American Academy of Pediatrics Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (published by the National Center for Education in Maternal and Child Health). For more information and resources on childhood immunizations and health activities, visit the Bright Futures website.
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