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The Consolidated Appropriations Act of 2021 (CAA) requires providers to inform health plans when there are any material changes to their provider directory information, as well as when they begin or terminate a network agreement. The CAA also requires health plans to verify each provider’s demographic information listed in the provider directory at least every 90 days. Providers are required to respond when a health plan, such as ours, requests information.
EmblemHealth and ConnectiCare are exploring ways to leverage our secure provider portals to simplify for you this verification process, as well as the submission of directory updates.
Currently, you may use the Provider Profile on the Provider Portal to add a new location or to remove a location. To request corrections to an existing location, you can send us a note through the Message Center; a link is available from the Provider Profile.
Organizations with delegated credentialing agreements should continue to manage their information’s accuracy through their regular monthly data file submission processes.
Other Data Accuracy Efforts
Medicare Advantage
For Medicare Advantage plans*, the Centers for Medicare & Medicaid Services (CMS) is looking to health care providers to review, update, and certify their National Provider Identifier (NPI) and related information in the National Plan & Provider Enumeration System (NPPES). When reviewing NPPES:
- Remove practice locations that are no longer in use.
- Correct inaccurate information in modifiable fields.
- Include all addresses where you practice, actively see patients, and where a patient can call and make an appointment.
- Exclude addresses where you could see a patient, but do not actively practice.
New York State Medicaid
In addition, New York State providers in our Enhanced Care Prime Network must notify Medicaid of any change of address, telephone number, or other pertinent information within 15 days of the change. For more information on this requirement and how to submit changes, see Reminder: Keep Your Directory Data Current.
*Includes: Medicare Advantage Organizations, Medicare Advantage - Prescription Drug Organizations, Section 1876 Cost Plans, Prescription Drug
Care Plans* for members who participate in our Case/Care Management programs are now available in the member’s Eligibility Details in the Member Management section of the provider portals.
For members with complex health care needs, coordination of care among their providers is critical. By sharing Care Plans through the portals, we offer greater transparency and more timely updates to all Care Team members. Care Plans document goals, progress, challenges, etc. If you need to update the Care Plan or ask a question about it, you can submit a message directly to the Care Team. Care Plan updates can be expedited based on the level of urgency you select. You will receive responses to questions or concerns by phone or email.
See our Provider Portal Care Plans quick reference guides (EmblemHealth/ConnectiCare) for instructions on using these new online tools.
To refer a member to one of our Care/Case Management programs, please contact us:
- 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.
*Some Care Plans, or sections of Care Plans, with highly sensitive information will not be available through the portal. Contact the assigned Care/Case Manager or follow the onscreen instructions to inquire about these plans.
Preauthorization Reminders:
Utilization Management (UM) letters for Commercial and Medicaid members are being posted to Preauthorization transactions. The responses you need may be available online before the mailed letter gets to you.
Faxing documents delays the review process. Take advantage of the provider portal’s ability to upload documents in support of your preauthorization requests, concurrent reviews, and discharge plans. Upload while creating the preauthorization request or go back into the request later to add more information.
Provider Portal Survey
We want to know what you think about the provider portal. Please take a few minutes to complete the survey at the top of the Home Page after you sign in to your portal account. This will help us prioritize updates to make the portals more useful and easier for you to use.
October is National Breast Cancer Awareness Month. Talking to your patients (between the ages of 40 to 49) about when to start breast cancer screening and how often to go for a mammogram is the first step toward early detection.
Women aged 50 to 54 years should be screened with a mammogram annually. For women aged 55 years and older, screening with a mammogram is recommended once every two years for those with normal risk or once a year for those with increased risk. Here are some tips for supporting your patients’ breast health:
- Have staff chart-prep and flag those patients that need an annual screening order placed during their visit.
- Help boost compliance by offering your patients a “standing order” for their annual screening mammogram, allowing them to complete the screening mammogram before their annual visit with you.
- Be sure your documentation meets CMS standards and that your provider credentials are attached to the correct ICD10 codes when ordering to ensure accurate data capture.
Additional resources for women can be found at the American Cancer Society website.
For men’s resources, visit:
In February 2022, EmblemHealth launched a survey for Medicare, Medicaid, and Health and Recovery Plan (HARP) members who have had a recent visit with their attributed primary care provider (measurement period runs from Jan. 1 through Dec. 31 each year).
Surveys are conducted via email, text message, and through outbound telephone calls with the purpose of measuring our members’ satisfaction with the care they receive from our network providers. Providers will be measured at both the site level and provider level. We will issue survey results to providers when we receive more than 10 responses for their practice.
Positive provider encounters create beneficial and constructive relationships, allowing a greater level of coordinated, timely care that helps best support the needs of patients. The results will also help us work with you to improve gaps in care and assist in the development of action plans to address key barriers.
Prior to the end of 2022, post-acute care (PAC) for EmblemHealth members will no longer be handled by eviCore. These services include home health care, skilled nursing facilities, acute rehabilitation, and long-term acute care hospital admissions. Instead of contacting eviCore, you will contact EmblemHealth to help arrange for PAC services and support. eviCore will continue to handle durable medical equipment for EmblemHealth members.
To help you better understand how this change impacts the members in your care, we will host a webinar to discuss the insourcing for all PAC services and the transitions of care program. The full list of session dates and times will be announced in the coming months. Please plan to join the session that’s best suited for your facility/provider type – no registration required. All sessions will be held via Microsoft Teams.
Attention Home Health Care Providers: Our provider portal has a Home Health Status report to give you a consolidated view of the preauthorization requests for the members under your care. See the quick guide and video on our Portal Training page in the Preauthorizations section for instructions on how to create the Home Health Status report.
MD Perspectives
Hello Colleagues:
It’s that time of year again – kids are back in school and soon winter will be knocking at our doors. For our pediatricians, that means most of their patients’ immunization records are up to date by now, but many of you may still be getting urgent last-minute requests coming in for sports clearances.
You may have limited time during an office visit, but as we all know, prevention is the key to good health. Use the opportunity to address:
- Immunizations
- Screenings
- Healthy habits
More than ever, immunizations will be an important area of discussion and medical guidance: COVID-19, Influenza, and Pneumococcal immunizations, to mention a few of the Centers for Disease Control and Prevention’s (CDC) recommendations.
If you need to guide those who are hesitant about getting immunized, words matter. For insights in speaking about COVID-19 and other vaccines, see the White Paper we published in April.
Screenings & Healthy Habits
Screenings are critical tools for health care professionals. They help guide our medical decisions and help us put our patients on the right path. Next month, for example, is National Breast Cancer Awareness Month. Encourage your patients to get their mammograms. Suggest they take part in one of the many fundraising walks as a way to get them moving. Maybe start your own team and invite them to participate. The exercise is good for their bodies, and helping others can help with depression. Getting out is good for you, too!
Preventive care is not limited to physical health. Be sure to screen for mental health issues and refer EmblemHealth patients and ConnectiCare patients to their respective behavioral health programs should you uncover an issue. You may want to take advantage of these October observances (and the resource materials offered on each of these sites) as ways to raise the need for, and importance of, screenings.
Oct. 2 – 8: Mental Illness Awareness Week
Oct. 7: National Depression Screening Day
Oct. 10: World Mental Health Day
You can also take advantage of these resources we have available to you and your patients:
Behavioral Health Clinical Practice Guidelines
EmblemHealth’s Clinical Corner – Behavioral Health
EmblemHealth’s Live Well Member Page for Mental Health
ConnectiCare’s Live Well Member Page for Mental Health
Even after a diagnosis is made, preventive care can help keep a bad situation from getting worse. There are just four months left to meet quality measures and submit SOAP notes for risk adjustment. Plan your practice’s time wisely. Proactively bring members in for needed care. Don’t get caught at the end of December with members not seen and holiday schedules preventing them from coming in for a needed visit.
One area where preventive care can have a great impact is with diabetes since its management requires support, motivation, and medication adherence. If you have patients that may need additional support, we at EmblemHealth and ConnectiCare are available.
Next month, we will share ways we can help you and your members with diabetes. If there are other health topics you would like our perspectives on, please write to us at EmblemHealthMedicalDirectors@emblemhealth.com.
Until next time!
Sandra
Sandra Rivera-Luciano MD, MHSA, FAAP
Sr. Medical Director/Utilization Management
While we welcome your suggestions, and ask that you do not send protected health information 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.
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