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We encourage our participating providers to send members to other in-network providers — when available and appropriate — to meet the member’s medical needs.

Members can choose from a variety of EmblemHealth and ConnectiCare networks. Many of our benefit plans limit coverage to in-network services. Even when out-of-network care is covered, members can benefit by using in-network providers to keep their costs down.

Our provider agreements and administrative guidelines generally require non-emergent/non-urgent care to be delivered by participating providers unless one is not available with the skills needed or is not available within a reasonable distance from the member’s home.

In cases where a participating provider is unavailable, as well as for continuity and transitional care needs, our Utilization Management team will review the non-participating provider’s request and make a determination. Preauthorization requests and supporting documentation may be submitted through our provider portals (emblemhealth.com/providerportal and connecticare.com/providerportal).

EmblemHealth works with Veradigm to promote risk adjustment education and gap closure efforts for EmblemHealth members. The 2024 EmblemHealth Risk Adjustment Program for Primary Care Providers (PCPs) is underway and runs from Jan. 1, 2024, through Dec. 31, 2024.

We encourage our PCPs to maintain accurate medical records and claims coding to capture the complete health status of all NY State of Health (The Official Health Plan Marketplace) members, Medicare Advantage HMO members, and Medicaid members.

The risk adjustment program is designed to help our PCPs identify members with chronic conditions who require an annual evaluation. The program also supports correct coding and documentation of the severity of their condition.

EmblemHealth needs evidence of ongoing care to support accurate reimbursement for government programs. As a bonus, PCPs who also complete a compliant provider alert and provide the supporting progress note(s) in Veradigm’s Collaborate Provider Portal can receive additional reimbursement.

Veradigm offers a series of free, 60-minute monthly webinars. Each session is followed by a question-and-answer period. We recommend that you and your staff take advantage of this educational opportunity. You may register for the monthly webinars through the secure provider portal or on our Veradigm webinar page.

Webinars are held on Tuesdays and Thursdays in the morning and afternoon to accommodate all schedules. Here are the March, April, and May topics:

• March 26 and 28: Give Yourself a Break: Coding for Orthopedic Conditions.
• April 23 and 25: Take a Deep Breath: Coding and Documentation for the Most Common Pulmonary Conditions.
• May 28 and 30: From the Heart: Coding and Documentation for Cardiovascular Conditions.

2024 Collaborate Provider Portal

Collaborate is a web-based tool that supports improvements in documentation, quality, and risk score accuracy. PCPs can visit Veradigm’s Collaborate Provider Portal via the EmblemHealth provider portal at emblemhealth.com/providerportal. See instructions for using the Veradigm Collaborate portal.

If you are interested in learning more about how you can view Veradigm’s provider resources and webinars, contact Veradigm’s Customer Support team at 800-877-5678 option 7 from 8 a.m. to 8 p.m., Monday through Friday or at support@veradigm.com.

Many of our providers have already received letters from our Quality Management department as part of our annual medical record review. This review is required for Healthcare Effectiveness Data and Information Set (HEDIS) reporting, Regulatory State reporting, and by the Centers for Medicare & Medicaid Services (CMS).

Compliance with HEDIS data collection is part of your Participating Provider Agreement(s). HEDIS and CMS consider missing records as noncompliant. Therefore, if you receive these letters — which contain a list of patients for whom we need medical records and a HEDIS Medical Record tip sheet — send us back the patient list and the section of the patient chart that shows the HEDIS measure has been met. The return fax number and secure email instructions will be noted in the letter.

NOTE: If you use outside vendors to collect medical records, it is your contractual obligation to make members’ medical records available to the plan — at no charge — for these reviews.

We appreciate your cooperation and thank you in advance for your prompt response. If you have any questions or concerns, call our HEDIS Helpline at 631-844-2420.

We all play an important role in impacting our members’ experience. This is captured every year through the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.

The CAHPS survey measures patients’ perception of their providers and their health plan. High CAHPS survey scores reflect positive relationships between our members and their providers and the ability to access timely care that is coordinated well. 

Your interaction with patients has a direct impact on their response to the CAHPS survey. Here are some tips to help you provide the best care to your patients:

• Engage in two-way communication.

Communicate in plain language. Explain the care provided and treatment plan in a way that is easy to understand. Listen carefully. Make sure patients also understand the care they receive from other providers.

• Evaluate the need for increased appointment availability.

Consider offering same-day appointments, evening and weekend appointments, an after-hours nurse line, and virtual visits.

• Equip patients with tools.

Give members material about their health conditions. Implement reminder systems and offer options to get their health records.

• Consider timeliness.

Limit telephone hold times to under 15 minutes and keep patients informed if you are running behind schedule. Try to schedule well visits/routine physicals within four weeks and non-urgent sick visits within 48 to 72 hours of request.

Learn more about CAHPS and how to improve your scores.