Office Visit

If Medicare-Medicaid dual-eligible individuals have their Part A and Part B cost-share fully covered by their Medicaid plan, or are Qualified Medicare Beneficiaries (QMBs), they are not responsible for their Medicare Advantage cost-share for covered services. Please do not balance bill these members for any other costs. Any Medicare and Medicaid payments for services given to these members must be accepted as payment in full. 

For EmblemHealth members, you can use ePACES to check whether the member has full or partial Medicaid benefits. For more detail, see EmblemHealth Medicare Advantage Plans. 

For ConnectiCare members, you can visit CT Department of Social Services or call 800-842-8440. For more detail, see ConnectiCare Medicare Advantage Plans. 

The following three payment reimbursement policies have been updated for both EmblemHealth and ConnectiCare:

• Medicare Preventive Grid – Additional diagnosis codes were added to the Bone Mass Measurement section to align the policy with CMS’ guidelines. (ConnectiCare and EmblemHealth)
• The COVID-19 Vaccine and Monoclonal Antibody Infusions Policy was updated to include a new code (0074A) effective May 17, 2022. (ConnectiCare and EmblemHealth)
• The Evaluation and Management (E&M) Services Reimbursement Policy was updated to include Initial Hospital Care/Subsequent Hospital Care – same-day guidelines. (ConnectiCare and EmblemHealth)

Starting Aug. 1, 2022, the following reimbursement policies are being introduced:

• Durable Medical Equipment (DME) in Office / Non-Facility Place of Service (Commercial and Medicare) (EmblemHealth and ConnectiCare)
• Durable Medical Equipment (DME) Rental vs. Purchase (Commercial and Medicare) (EmblemHealth and ConnectiCare)
• The updated EmblemHealth’s Coding Edits Policy identifies the edits that will now apply to our PPO members with Medicare PPO and commercial PPO plans for both City of New York and non-City PPO members.

ConnectiCare and EmblemHealth are aligning how they communicate preauthorization requirements. EmblemHealth has separated the EmblemHealth Preauthorization List into two separate documents – one to house services covered by members’ medical benefits, and one to house services covered by members’ pharmacy benefits. (We discuss the changes to our medical preauthorization lists in a related story in our Clinical Corner section.) As part of this effort, the ConnectiCare Pharmacy Preauthorization List has also been reformatted. Both lists now include the July 1, 2022 CMS code updates.

If you need help navigating our provider portals, see our videos, quick guides, and Frequently Asked Questions pages:

• EmblemHealth Videos and Guides
• EmblemHealth FAQs
• ConnectiCare Videos and Guides
• ConnectiCare FAQs

If you still have questions or need additional support, you may contact Provider Customer Service:

EmblemHealth: 866-447-9717

ConnectiCare: Commercial: 860-674-5850, Medicare: 877-224-8230

EmblemHealth continues to partner with Pulse8™ to promote risk adjustment and gap-closure education for PCPs caring for EmblemHealth members enrolled in these products:

• New York State of Health (NYSOH) Marketplace
• Medicare HMO
• Medicaid

Pulse8 offers free monthly webinars to help educate providers on best practices regarding the risk adjustment process, including accurate medical record documentation and claims coding to capture the complete health status of each patient. We encourage PCPs and/or their support staff to register for Pulse8’s monthly webinars. Go to Pulse8’s Public Event List and search by webinar date or title.


These Pulse8 webinars are generally held on Tuesdays and Thursdays at 8:30 a.m. and 12:30 p.m. Here are the July and August topics:

• July 26/28 – The Reality of Coding for the Most Prevalent Endocrine Disorders
• Aug. 23/25 – Filtering the Guidelines of Correct Documentation and Coding for CKD and Associated Manifestations

If you are interested in learning more about how you can access Pulse8’s provider resources and webinars, please contact Pulse8’s Customer Support team Monday through Friday, 8 a.m. to 8 p.m. at 844-8PULSE8 (844-878-5738) or mail to ProviderEngagement@Pulse8.com. 

We recommend that you take advantage of the training opportunities offered by CMS’s Medicare Learning Network and eMedNY.