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All hospitals and critical access hospitals are required by CMS to provide Medicare beneficiaries, including Medicare Advantage enrollees, with the OMB-approved Medicare Outpatient Observation Notice (MOON). The MOON and instructions for completing it are available on CMS’ website.

Beginning Aug. 30, EmblemHealth and ConnectiCare will enhance our existing claims editing program by implementing new coding validation edits. Coding validation edits evaluate the correct use of overriding modifiers such as modifiers 25, 59, XE, XS, XP, and XU. Our goal is to improve the overall accuracy of our claims processing for all lines of business by ensuring the correct modifiers are used. To support of this change, we are introducing a Coding Validation Payment Integrity Policy for both EmblemHealth and ConnectiCare.

We are introducing two new reimbursement policies that apply to both EmblemHealth and ConnectiCare members:

• The new Readmission Policy (EmblemHealth and ConnectiCare) will go into effective Aug. 30, 2022. The policy governs when a readmission will be treated as a separately payable new admission and when as a continuation of the first inpatient stay.


• The Evaluation & Management Services (E&M) Policy (EmblemHealth and ConnectiCare) will replace our Supplemental E&M Policy. In addition, effective Sept. 1, 2022, EmblemHealth will no longer reimburse consultation codes 99241-99255 for our GHI PPO City of New York Plans. Non-consultative E&M codes may be utilized based on the code that best describes the service performed.

The following reimbursement policies have been updated:

• ConnectiCare updated the ASC Grouper Policy to include new codes effective April 1, 2022. Ambulatory surgical groupers will be paid according to surgical contracted rates when billed with revenue codes 360 or 490. If surgical services are billed with revenue codes other than 360 or 490 and the claims contain charges for anesthesia and/or recovery room, claims will be paid according to the surgical contracted rates unless otherwise negotiated.


• EmblemHealth’s Coding Edits Policy was updated to include the additional edits that will be implemented Aug. 1, 2022.


• The COVID-19 Vaccine and Monoclonal Antibody Infusions Policy, which applies to both EmblemHealth and ConnectiCare, was updated to add new codes (Q0220, Q0221, Q0222, M0220, M0221, M0222, M0223, and M0240). 


• ConnectiCare has updated the Experimental, Investigational or Unproven Services Policy to include new codes effective April 1, 2022. ConnectiCare defines the terms “investigational” or “experimental” as the use of a service, procedure, or supply that is not recognized by the health plan as standard medical care for the condition, disease, illness, or injury being treated. A service, procedure, or supply includes, but is not limited to, the diagnostic service, treatment, facility, equipment, drug, or device.

As announced in February, we are introducing a new reimbursement policy for Telehealth/Virtual Care Services (EmblemHealth and ConnectiCare) effective June 1. We ask our providers to use telehealth visits, wherever possible, to close gaps in care, meet Healthcare Effectiveness Data and Information Set (HEDIS^®) measures, increase Consumer Assessment of Healthcare Providers and Systems (CAHPS^®) scores, and improve risk score accuracy.

Note: For EmblemHealth and ConnectiCare Medicare Advantage plans, the enforcement of the Place of Service (POS) requirements (limiting reimbursement to POS-02 Telehealth Provided Other than in Patient’s Home and POS-10 Telehealth Provided in Patient’s Home) will go into effect at the end of the public health emergency (PHE). We ask providers to use the telehealth modifiers listed in the policies to facilitate correct payment.

Following are the recent Medical Policy updates:

• The Functional Endoscopic Sinus Surgery (FESS) medical policy is being retired for both EmblemHealth and ConnectiCare.
• The Radiofrequency Ablation for Spinal Pain medical policy has been revised for EmblemHealth.

Let Us Know When Directory Information Changes

If a provider in your practice is leaving, inform us as soon as possible. To report other changes, sign in to your Provider/Practice Profile for EmblemHealth or ConnectiCare. If you participate with us under a delegated credentialing agreement, have your administrator submit these changes. See more on how to submit changes for EmblemHealth and ConnectiCare.

Remember to review your CAQH application every 120 days and ensure you have authorized EmblemHealth as an eligible plan to access your CAQH information.

The EmblemHealth Provider Manual is a valuable online resource and an extension of your Provider Agreement. It applies to all EmblemHealth 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. The manual is updated regularly, so be sure to download a current PDF of the chapter when looking for information. You can find the EmblemHealth Provider Manual on the top right side of our website.

Our EmblemHealth Neighborhood Care and ConnectiCare Centers provide:

• One-on-one customer support to help members understand their health plan.
• Access to community resources.
• 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 of your patients. View our locations and upcoming events for EmblemHealth Neighborhood Care and ConnectiCare.