Office Visit

Hello Colleagues,

Fall starts the unofficial eating season with Halloween treats and Thanksgiving feasts, followed by December holiday parties galore! For those with diabetes, these special occasions can be challenging. For those who do not know they have diabetes, these indulgences can take a heavy toll. The issue is so serious that November has a dedicated month (American Diabetes Month), week (National Diabetes Education Week: November 6 – 12), and day (World Diabetes Day: November 14) to call attention to it.

We understand the complexity of living with, and treating, diabetes. We usually recommend an interdisciplinary approach informed by current, evidence-based guidance. Medical societies update their guidelines frequently (see below for the current guidance) and we keep an eye out for their changes to stay informed.

We are here to assist you with the extra help you may need coordinating care and encouraging your patients to practice self-care. For example, when one member needed supplies to check their blood sugar, our Care Manager coordinated with their primary care provider and pharmacy to have $0 copay testing supplies sent directly to the member’s home. The Care Manager then made sure the member had full understanding of what they needed to do to keep their diabetes under control.

We have many resources to support you and your patients. We recently added care plans to our provider portal to give all treating providers easy access to them and to support coordination of care. See below for programs, classes, and materials we have available.

Chronic Obstructive Pulmonary Disease

Diabetes is only one of many complex conditions our members are dealing with. November is also COPD Awareness Month.

Chronic obstructive pulmonary disease (COPD) refers to a group of diseases that cause airflow blockage and breathing-related problems. We want to support you while you take care of our members. Services available for your patients with COPD include dedicated Care Management programs for patients who need disease education and coordination of care.

Vaccines

October is also the time of year for all of us to continue to drive home the message concerning the importance of vaccinations. Visit CDC.gov for vaccine considerations and what health care professionals should know about:

• MVP (formerly referred to as monkeypox)
• Polio
• Influenza
• COVID-19

We recommended vaccinations be considered according to age group. See the Prevention information available to our members.

Programs, Classes, and Resources

• We offer Care/Case Management programs for patients with complicated diabetes with comorbidities such as coronary artery disease (CAD) or chronic kidney disease (CKD), COPD, complex care, and more. Members have access to nurse care managers, social workers, and pharmacists depending on their individual needs. Established care plans are shared on our provider portal—so set up an account if you haven’t already. To refer a member to one of our Care/Case Management programs, you may contact us at:
  • EmblemHealth: See our Care Management Programs page for program descriptions, ways we can support you and your patients, and program-specific contact information. If you need general assistance, you can call 800-447-0768 Monday through Friday from 9 a.m. to 5 p.m.
  • ConnectiCare: 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.
• EmblemHealth’s Pharmacy Programs can help with comprehensive medication reviews and we offer a Medicare-specific Medication Therapy Management Program to support adherence. We strive to integrate the latest pharmacological updates to prevent diabetes complications.
• Online virtual and in-person classes are available at our EmblemHealth Neighborhood Care and ConnectiCare Centers.

 Current Medical Society and CDC Guidelines

• American Diabetes Association
  • Standards of Medical Care in Diabetes – 2022
  • Practical Information for Primary Care
• KDIGO guidelines focus on topics related to the prevention or management of individuals with kidney diseases.
• Centers for Disease Control and Prevention – COPD Guidelines, Reports, and References

  Our Provider Resources

• Medicaid National Diabetes Prevention Program
• 2022 Quality Measure Resource Guide including diabetes quality measures

Our Member Resources

• GHI City of New York Members’ Diabetes Program
• EmblemHealth’s Diabetes Health and Chronic Obstructive Pulmonary Disease
• ConnectiCare’s Let’s Talk About Diabetes

What’s Next?

Next time, we’ll discuss our population health strategy and how we, as physicians in the plan and as practicing physicians in our network, play a role in shaping the future of our companies.

Sandra

Sandra Rivera-Luciano MD, MHSA, FAAP

Sr. Medical Director/Utilization Management

If there are other health topics you would like our perspectives on, please write to us at EmblemHealthMedicalDirectors@emblemhealth.com.

While we welcome your suggestions, we ask that you do not send protected health information (PHI) or patient-specific issues to this mailbox. This mailbox should not be used for Complaints, Grievances, Appeals, or Claims Inquiries. The Claim Inquiry and Message Center features in the Provider Portals (EmblemHealth|ConnectiCare) should be used for those issues.

MPV vaccine (formerly known as monkeypox) administration is a covered benefit for EmblemHealth Medicaid members. We will reimburse providers for the administration of these vaccines. For more information on immunizations, mandatory reporting, and testing locations for MPV, visit our provider hub for State-Sponsored Programs.

View the latest Medicaid Updates from the New York State Department of Health.

EmblemHealth and ConnectiCare have partnered with Quest Diagnostics to provide free in-home colorectal cancer and diabetes screening test kits to our eligible Medicaid and Medicare members. This program aims to increase screening adherence and improve health outcomes.

Eligible EmblemHealth Medicaid and Medicare members can receive:

• A fecal occult blood test (FOBT) to screen for colorectal cancer

Eligible ConnectiCare Medicare members can receive:

• FOBT for colorectal cancer
• The A1c test for diabetes

Questions about this program can be directed to QualityProviderengagement@emblemhealth.com. 

Starting Jan. 15, 2023,  the EmblemHealth Preauthorization Lists  will include four new requirements for genetic/molecular services (HCPCS Codes: 0012M, 0013M, 0014U, and 0017M). For details, see the Notable Changes announcement.

It’s important for our members to get the right care at the right time. See our Appointment Availability Standards During Office Hours & After Office Hours Access Standards brochure available on the Provider Toolkit in the Provider Resources section of our provider website. Refer to it often and share it with appointment schedulers.

The following EmblemHealth and/or ConnectiCare medical policies are being retired:

• Noncoronary Vascular Stents
• Total Ankle Replacement
• Transurethral Radiofrequency Micro-Remodeling for Female Stress Urinary Incontinence

The following medical policies have been revised for both EmblemHealth and ConnectiCare:

Bariatric Surgery (EmblemHealth|ConnectiCare): Added language communicating that the Overstitch device (endoscopic revision) is considered investigational.

Cardiac Event Monitors (EmblemHealth|ConnectiCare): Added language communicating that CPT 0716T (Acoustic waveform recording with automated analysis and generation of coronary artery disease risk score) is considered investigational.

Noninvasive Prenatal Testing (NIPT) for Fetal Aneuploidy (EmblemHealth|ConnectiCare):

• Expanded Commercial coverage to include twin pregnancies effective Nov. 12, 2022.
• Removed Fetal Rhesus D MCG cross reference

Obstructive Sleep Apnea Diagnosis and Treatment (EmblemHealth|ConnectiCare): Added BMI ≥ 45 as a covered indication for polysomnography.

EmblemHealth’s Gene Expression Profiling:

• Added whole genome/exome sequencing section citing medically necessary MCG criteria sets
• Updated Limitations/Exclusions section citing investigational MCG criteria sets

ConnectiCare’s Infertility (Commercial): Removed language within Donor Services section pertaining to age 40.

One Updated Medical policy – ConnectiCare:

ConnectiCare has updated the Experimental, Investigational or Unproven Services Policy to include additional codes – see revision history for applicable changes/updates with effective dates.

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.

If a provider in your practice is leaving, please 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, please 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. You can find the EmblemHealth Provider Manual on 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, provide access 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 of your patients. View our locations and upcoming events for EmblemHealth Neighborhood Care and ConnectiCare.