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As 2025 nears, we ask you to please review our newly published EmblemHealth Annual Provider Notice (links below) that covers anticipated changes to our networks, benefit plans, and policies.

Now is a good time to review key practices to improve your patient’s experience including expected appointment scheduling time frames, appointment wait times, and use of our provider portal to streamline preauthorization requests.

For our Connecticut providers, we updated the Commercial Networks and Benefit Plans page and the Medicare Advantage pages on connecticare.com to show how the different networks and their associated plans accommodate different members’ needs.

Here are links to the Annual Provider Notice and other helpful resources:

• 2024-2025 Annual Provider Notice.
• 2025 Summary of Companies, Lines of Business, Networks and Benefit Plans.
• 2025 EmblemHealth Plans That Do Not Need Referrals.
• EmblemHealth Commercial Networks and Benefit Plans.
• ConnectiCare Commercial Networks and Benefit Plans.
• EmblemHealth State Sponsored Programs.

Starting Dec. 9, 2024, we are making some changes to both simplify our non-delegated credentialing and recredentialing processes for professionals and to improve our provider directories.

Initial Credentialing

For first-time credentialing, we will continue to require a Council for Affordable Quality Healthcare (CAQH) ID. We will not process applications submitted without one.

Recredentialing

We are expanding our partnership with CAQH to include our recredentialing processes. We will import your CAQH information into our system. This will translate into less administrative work for our providers.

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.

See how to communicate data changes with us going forward:

EmblemHealth | ConnectiCare.

EmblemHealth and ConnectiCare will observe the 37th World AIDS Day on Dec. 1 by focusing on prevention and offering you support in caring for our members who have HIV/AIDS. The theme for 2024 is “Collective Action: Sustain and Accelerate HIV Progress.”

Our HIV/AIDS Care Management Programs and Resources

EmblemHealth has a free, dedicated HIV/AIDS Care Management program to help members find community resources and navigate the health care system. Members can enroll by calling us at 800-447-0768 (TTY: 711), 9 a.m. to 5 p.m., Monday through Friday.

You can also refer your members to HIV/AIDS Resources. For more information about caring for members with HIV/AIDS, see the New York State Department of Health (NYSDOH) AIDS Institute. ConnectiCare offers members with HIV/AIDS support through our Care Management program. To refer a member, call 800-390-3522 Monday, Thursday, and Friday from 8 a.m. to 4 p.m., or Tuesday and Wednesday from 8 a.m. to 7:30 p.m.

HIV/AIDS Prevention – PrEP

HIV PrEP is a preexposure prophylaxis (PrEP). It may protect patients against HIV, even if their partner has HIV. 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 PrEP Resources.
• NYSDOH Online Resources for Education, Information, and Services.
• HIV/AIDS Services in Connecticut.

Complete and accurate diagnosis coding is important to ensure seamless collection of administrative data and reduce the burden of medical record review. To learn best practices for documenting and coding each of the high-risk conditions as identified by the Office of Inspector General, watch this video.

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:

• Nov. 19/21 State of Mind: Documentation and Coding for Depression and Other Behavioral Health Disorders.
• Dec. 17/19 Narrow It Down: Documentation and Coding for Vascular Disorders.

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. Sarah, a 27-year-old mother of two, uses the WellSpark resource library for meal planning tips and recipes to help her family eat healthy and stretch her food budget.

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.

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.

Here is the most recent update:

On Oct. 2, 2024, newly-created content for Dispute Resolution for Commercial and Medicare Plans was added to the ConnectiCare Coverage Guidelines page.