Your source for important provider news and updates.
October 2024
Office Visit
Feature Stories
In response to feedback from provider portal users, we made a few adjustments to the new workflow for saving draft preauthorization requests and emergent inpatient admission notifications.
Time Frame Change: Drafts Will Be Saved For 120 Hours
We will be expanding the time frame for saving draft preauthorization requests and emergent inpatient admission notifications to 120 hours.
Enter The NPI When Searching For Drafts
On the Incomplete Preauthorization Requests & Emergent Inpatient Admission Notifications screen, we added a field to enter the requesting or servicing provider’s/facility’s NPI to narrow down the number of drafts shown.
Expanded Provider Search
We expanded the provider search within the Preauthorization Requests and Emergent Inpatient Admission Notifications by lifting the requirement that the user and provider be linked under the same tax ID. This will help our ancillary providers submit requests for their services on behalf of a doctor or other practitioner.
Don’t Forget to Hit Submit
We noticed that some providers enter all the required information for a request/notice, but then do not actually submit the request/notice. You MUST click the Submit button on the bottom of the MCG screen to send us your request/notice.
Select The Correct Category and Sub-Category for Grievances and Appeals
To help us get your grievance or appeal to the right staff faster, look up the specific claim or preauthorization request you wish to dispute on the provider portal. On the Claims Details page or the Preauthorization Details page, use the Ask a Question button to create a message. Be sure to select the following:
Category: Grievance and Appeals
Sub-Category: Post Service Appeal
You can look up a claim and use the Ask a Question feature on the Claims Details page to:
- Request claims status.
- File a grievance; a claims dispute that does not involve a medical necessity decision.
- Respond to a claims denial request to submit records or other supporting documentation.
Note: The provider portal cannot accept corrected claims.
The EmblemHealth Access, Availability, and After-Hours Coverage Standards are monitored using random audits. We want you to pass if you are selected for one. It’s important to us that our members get the care they need in a timely manner.
One common mistake providers make is not adhering to the office waiting time standard. Members with appointments should be seen within 15 minutes, but no later than 30 minutes, of their scheduled appointment time or arrival time, whichever is later. If a delay is unavoidable, the member should be informed and offered alternatives.
Please take the time to periodically review the standards and make sure all staff who answer your phone and schedule appointments have a copy of — and are familiar with — those standards and requirements for scheduling patient appointments.
Teaching your patients with diabetes how to control their blood sugar is the best way to help them manage their condition and improve their health. EmblemHealth recently launched a diabetes program in the Bronx, just in time for Diabetes Awareness Month in November.
According to the Centers for Disease Control and Prevention (CDC), diabetes is number three on the list of top chronic conditions in the United States after cancer and heart disease. The American Diabetes Association (ADA) has provided the following preventive care recommendations for people living with diabetes:
- Regular A1C testing.
- Kidney function testing.
- Ankle-brachial index.
- Annual retinal eye exam.
- Cholesterol and triglycerides testing.
- Blood pressure testing.
For additional information and resources, please see online information about our diabetes program in The Bronx and the ADA’s Health Checks for People with Diabetes and diabetesjournals.org.
For more information and assistance with coding guidance for quality gap-in-care closure, please visit our Quality Improvement website and download the EmblemHealth and ConnectiCare Quality Measure Resource Guide.
Lung cancer is the leading cause of cancer deaths in America, according to the American Cancer Society. The average age of people when diagnosed is about 70.
Nov. 9 is National Lung Cancer Screening Day. Screening can detect lung cancer early, when it is more likely to be curable. According to the American Lung Association, if lung cancer is caught before it spreads, the likelihood of surviving five years or more is 63%.
The American Cancer Society and U.S. Preventive Services Task Force recommend yearly lung cancer screening with a low-dose CT scan (LDCT) for current and former heavy smokers ages 50 and older.
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