Office Visit

The preauthorization request and emergent inpatient admission notices (request/notice) features on our provider portal just got easier to use. 

Here are the key changes you will start to see Sept. 16, 2024:

• The ability to save a draft request/notice for up to 96 hours. This will allow time to collect the clinical information or hand off the case to someone else with the clinical expertise to address the MCG/Clinical Criteria and provide supporting documentation. 
• The Submit Request button will not activate until expected clinical information is addressed and documents are attached. 
• The number labeled “Authorization” on the MCG screen is the “Draft Number” or “Reference ID” and is not considered an approval of the preauthorization or initial concurrent review.
• You will see the addition of a new Take action box on the home page and an item in the Preauthorization menu that will take you to a list of unsubmitted draft requests/notices.
• The duplicative screen for uploading documents has been removed. All documents will need to be attached using the MCG screen that collects clinical information.
• The identified Contact will be sent email reminders before a draft expires and again if it expires.

What These Changes Mean to You

All providers associated with the request/notice will be able to see a list of incomplete drafts that they can open and complete. This means that more than one person can contribute to the request/notice. For example:

• The primary care provider who sends their patient to a specialist for a procedure may start the preauthorization request, and the specialist who is selected will be able to address the clinical criteria and attach supporting documentation.
• The emergency room staff can start the notice and the clinical staff treating the admitted member can finish it once the actual diagnosis is determined and clinical information for a concurrent review is available.

Note: If the initial diagnosis is different from the actual diagnosis, we recommend that you enter a new notice so the portal asks you for the applicable clinical criteria. 

EmblemHealth is inviting our members and your Bronx patients to join us for the launch of our community diabetes wellness program. We encourage you to pass this information on to patients who need help managing or preventing diabetes.

This free event is open to the public and will be held at EmblemHealth Neighborhood Care, 254 E. Fordham Road from noon to 3 p.m. on Tuesday, Oct. 1. There will be A1C screenings, connections to community resources, and conversations with a diabetes educator.  

Register or learn more about our diabetes programs here.   Walk-ins are welcome, but registration is encouraged.

We will continue to keep you informed of future wellness events to share with your patients.

The annual Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey evaluates member satisfaction with their health plans, prescription drug services, and their providers.  

Members’ experiences and interactions with us as their health plan and with you as their provider affect the outcome of the survey. That is why it’s so important for all of us to work together toward the goal of improving member satisfaction.

One of the survey questions is: “Have you had a flu shot since July 1, 2024?” Measure adherence is determined by member response.

The measure description is the percentage of patients 65 years of age and older who received a flu vaccination between July 1 of the measurement year and the date the CAHPS survey was completed.

How You Can Help Improve CAHPS Scores

• Identify an “Immunization Champion” to lead and monitor flu vaccination efforts at the office.
• Institute a Standing Order Program to allow nonphysician clinical staff to assess vaccination eligibility and administer vaccinations.
• Turn on reminders/prompts for the flu vaccine if on electronic medical records (EMR). Review vaccine status in the EMR.
• For all patients needing a flu vaccine, flag the charts (if not on EMR) with a brightly colored sheet.
• Provide a list of pharmacy locations if you don’t offer the flu vaccine.
• Address any hesitations the member may have about receiving the flu vaccine.
• Educate patients that the seasonal flu vaccine helps protect against the influenza viruses that research indicates will be the most common in the upcoming season. Each season requires a different vaccine.

Discuss with your patients the ways to help prevent catching or spreading the flu. We’re reminding our members to visit their doctor or go to a local pharmacy to get their vaccination.

Keep up to date with the Centers for Disease Control and Prevention’s flu recommendations and educational resources.

WellSpark Health’s broad range of well-being resources are helping our members achieve positive behavioral and lifestyle changes.

Here is just one of WellSpark’s success stories:

A 43-year-old Hispanic female with uncontrolled high blood pressure worked one-on-one with a WellSpark health coach. She improved her diet, began to exercise more often, and felt less anxious. This resulted in fewer trips to the emergency room.

To see what benefit plans offer WellSpark’s resources, review the 2024 Summary of Companies, Lines of Business, Networks & Benefit Plans. We ask that you encourage eligible members to sign in to the member portal to see what is available to them and to take advantage of the support offered.

Learn more about WellSpark resources that may be available to your EmblemHealth and ConnectiCare members:

• EmblemHealth commercial members.
• ConnectiCare commercial members.
• EmblemHealth Medicare members.
• ConnectiCare Medicare members.
• City of New York Gold HMO Preferred plan members.

Our EmblemHealth Neighborhood Care locations and ConnectiCare Centers provide one-on-one customer support to help members understand their health plan, provide connection 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 your patients. View locations and upcoming events for EmblemHealth Neighborhood Care and ConnectiCare Centers.

Note: The EmblemHealth Neighborhood Care Physician Referral Form has been updated to include the new Bronx locations.

Let Us Know When Directory Information Changes

If a provider in your practice is leaving, please inform us as soon as possible. To report other changes, as required by our participation agreements, 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. A key resource is the Access & Availability Standards that set the expected time frames for appointment availability, appointment wait times, and after hours coverage. You can find the EmblemHealth Provider Manual in the top navigation menu of our provider website, emblemhealth.com/providers.