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Emblemhealth incbu ine week

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This listing also captures annual procedure coding updates since December Many EmblemHealth and ConnectiCare members have plans which give them access to providers in both organizations. See the Summary of Companies, Lines of Business, Networks, and Benefit Plans to see which plans and networks offer reciprocity, details on PCP and referral requirements, out-of-network coverage, copays, and maximum out-of-pocket limits.

These members will not have access to EmblemHealth providers. Headlines You May Have Missed. Medical Policy Updates. At the top of the page, select Commercial or Medicare to see the applicable policies. Below, find the new and revised medical policies published since December We routinely evaluate claims for coding, billing accuracy, and appropriateness. Providers are required to supply requested supporting information such as itemized bills and medical records.

Note: Neither additional records nor amended records will be accepted once an audit review is complete. In addition, we added outpatient APC audits to our payment integrity correct coding evaluations effective Aug. We are contracted with Optum to perform these audits on our behalf. Notification via letters, their audit findings, and instructions on how to appeal their determinations will be coming directly from Optum.

Reimbursement Policies. Below is a summary of the substantive updates posted since December including new policies that will go into effect in Pulse8 offers free webinars for patient management and ICD coding.

To register, go to pulse8. See the full schedule for If you have questions, or would like to set up a private session for your practice, please email ProviderEngagement Pulse8.

Their hours are 8 a. Learn more about the Pulse8 Collabor8 risk adjustment program. You can manage your learning, track credits online, and complete activities at your own pace. On Oct. See the Pharmacy Balance Billing guide for instructions. Our Express Scripts, Inc. Preferred pharmacies help members save on prescription drugs and improve medication adherence, so we ask that you remind members to use a preferred pharmacy when you can.

Standard pharmacies that participate in the Preferred Value Network but only offer standard cost-sharing include:. Pharmacy locator links are available on our website to help you and your members find a nearby participating pharmacy. Pharmacy Taking medications as prescribed medication adherence is important for treating and controlling chronic conditions.

Doctors play an important role in helping members stay adherent. Here are some steps as a doctor you can take to help members remain adherent:. Please help your members stay adherent and save on their prescription drugs by recommending members switch to preferred mail order:.

Both Federal and State laws protect dual eligibles from being balance billed. For more information about coordinating benefits with Medicaid for pharmacy providers, see the Pharmacy Balance Billing guide for instructions.

For a list of frequently used phone numbers, addresses, and websites, see the Directory Chapter of the EmblemHealth Provider Manual. You can save time by checking Provider Help and Support page's compilation of frequently asked questions and answers before contacting Customer Service.

Provider Portal. Take advantage of our new provider portal. You can check member eligibility and benefits, review claims status, update your practice information, create a referral, request preauthorization, and more.

Plus, no more signing in and out of our sites. You can now see information and process transactions for all of our members with one User ID! Our new Provider Portal is designed to be simple and intuitive.

Should you need help, see the How do I use the Provider Portal? Tab of the Provider Help and Support page for key things you should know.

If you first need to set up an account, or have a question about a transaction, see our provider portal frequently asked questions webpage to address the most common issues our Provider Customer Service team has been receiving.

To help you with the online transactions, we have posted a series of videos and user guides to help you step by step through each one. The online Provider Manual is an extension of your contract with us. It has information about your administrative responsibilities, contractual and regulatory obligations, and best practices for helping members navigate our delivery systems.

Revisions are made as policies are renewed, new programs are introduced, and rules change. EmblemHealth Neighborhood Care. EmblemHealth Neighborhood Care provides in-person customer support, access to community resources, and programming to help the community learn healthy behaviors. Members and non-members alike can visit Neighborhood Care and take advantage of our classes, tools, and face-to-face support.

The health and wellness classes support the different dimensions of wellness, including physical, financial, social, and emotional. Neighborhood Care does not provide medical services. Instead, our role is to help practitioners manage patient care by supporting the practitioner-patient relationship. Member Materials. The Provider Toolkit has guides and quick references to help with the administration of our plans. The Toolkit is where we house Welcome materials for new providers.

Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office. Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan.

Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage. Switch to: members brokers employers.

Sign in Contact Us Search. Navigation Open. Switch to:. Clinical Corner. Quality Improvement Find our Quality Improvement programs and resources here. Search Our Quality Improvement Page. Claims Corner. Reimbursement Policies Payment processes unique to our health plans Payment Integrity Policies How we pursue payment accuracy.

Provider Manual. Provider Manual Find the specific content you are looking for from our extensive Provider Manual. Search the Provider Manual. Dental Corner. Welcome Dental Providers Find a Dentist. Home Annual Provider Notification. The links now go to permanent webpages where you will be able to find product-specific information all year long: Bridge Program Note: Providers who are only contracted with EmblemHealth Plan, Inc.

Members should not be turned away. These surveys ask about getting appointments and care quickly, ease of getting needed care, ease of communicating with staff and doctors, getting help in coordinating care, flu vaccination, and the overall experience of getting care.

Positive experiences result in better survey ratings. The sections below include tips for improving the patient experience which you can apply in your practices. Here are some non-clinical tips to boost your measurement scores: When billing, use the correct codes which relate to ALL services given during the visit. This may reduce chart collection. Help your patients get care quickly: Leave open appointments for sick visits and urgent appointments.

Ensure patients understand timeline for follow-up. Discuss how to access care after hours. Assist your patients with getting the care they need: Educate your patients on the importance of preventive services. Follow-up with specialists of patients to ensure continuity of care.

Ask patients what their top health concerns are. Use the teach-back method to ensure understanding. Care Coordination: Assist in coordination of non-emergency transportation, if necessary.

Link patients with community resources to facilitate referrals and respond to social service needs. Collaboration is KEY! Collaborative activities EmblemHealth continually conducts activities to improve behavioral health and general medical care, including collaboration with behavioral health practitioners. Implement primary care guidelines for assessing, treating, and referring common behavioral problems.

Increase non-behavioral health care practitioner satisfaction with feedback from behavioral health care practitioners. Improve procedures for treating hospitalized members with coexisting medical and behavioral health conditions. Improve management of elderly members with indications of depression and multiple behavioral health care medications. Educate primary care practitioners about appropriate indications for referring patients with hyperactivity disorder, substance use disorders, or depression to behavioral health care specialists.

Implement a prevention program for behavioral disorders commonly managed in the primary care setting. Appropriate diagnosis, treatment, and referral of behavioral health disorders commonly seen in primary care. Appropriate use of psychotropic medications. Oversight of access to treatment and proactive follow-up for members with coexisting medical and behavioral disorders. Preventive behavioral health care program implementation in both primary and secondary settings.

Accommodations to be made for the special needs of our members with severe and persistent mental illness. Confidentiality for domestic violence or endangered victims Please let your affected patients know they are entitled to these privacy protections: Group policy members may ask us to enforce an order of protection against the policyholder or other person. We will not disclose their address or telephone number for the duration of the order. We will accommodate any reasonable request for a covered individual to receive communications of claim-related information by an alternative means or at an alternative location.

To satisfy this requirement, providers must complete one of these two programs: OASAS-approved training. Two Uniform Network Provider Training modules. More educational materials OMH also offers a host of educational materials on its website for behavioral health providers. Claims Corner The Claims Corner section of our provider website is part of the EmblemHealth Provider Manual and houses Administrative Guidelines described in our participation agreements.

Timely Filing Reminder The EmblemHealth timely filing time frame is days from the date of service, unless EmblemHealth is the secondary payor or the participation agreement states an alternative time frame to be applied.

Here is a summary of the key updates posted this last year and those anticipated for Preauthorization List Reductions and Updates for Good news! Here are some time-savers for hospital staff: Convenient ER admission and newborn notifications: No more need to call or fax; these transactions can now be done online for all our members.

Hospitals can now notify us on the portal — for all EmblemHealth and ConnectiCare managed members — up to 60 days after an admission. Mandatory Reporting To ensure public safety and to track conditions affecting public health, the federal government, New York State and New York City agencies have enacted laws that must be followed by health care professionals.

Approved Acessa System laparoscopic radiofrequency ablation for uterine fibroids Added commercial, eff. Remind members to track their refills and make an appointment for a new prescription before they run out.

Educate members on the side effects of the medications and how to treat them. Help identify and resolve barriers to members not taking their medication as prescribed. Consider prescribing day supply prescriptions for maintenance medications. Your coverage is largely dependent on your insurance EmblemHealth plan and the level of care you require. The passing of the Affordable Care Act made coverage for essential health services, including substance abuse treatment and mental health services, more accessible.

Innovative Health alcohol and drug rehab center that offers intensive outpatient rehab for substance use disorders. We treat alcohol and drug addiction and other mental health disorders. We are a leader in comprehensive alcohol and substance use treatment with evidence-based individualized treatment in New York state. At Innovative Health, you have several options for treatment, including telehealth services.

We offer medication-assisted treatment, behavioral and mental counseling, and evaluations. Your out-of-pocket maximum is the most you will have to pay for covered services per year. If you are concerned that your insurance will not pay for rehab services or cover the entire cost of substance abuse treatment, payment options are available.

Health insurance coverage is processed with your insurance provider. Once your claim is processed, your remaining balance will be available, and we have payment plans available to take the financial burden out of rehab.

At Innovative Health, we believe everyone deserves access to addiction treatment. Medication-Assisted Treatment, or MAT, is the use of medications in combination with detox and addiction therapy to treat substance use disorders. MAT is an effective treatment that helps with withdrawal symptoms from certain substances. Medication-assisted treatment is primarily used to treat addiction to opioids and prevent an opioid overdose.

For opioid use disorder, we provide monthly injections of Suboxone, Buprenorphine, or Sublocade. To treat alcohol use disorder, Naltrexone or Vivitrol monthly injections are available. These medications are typically covered by insurance. If you require MAT, it is typically an ongoing, long-term treatment plan.

Generally, MAT also requires mental and behavioral health services. You may be wondering if your insurance policy covers MAT treatment and additional treatment. Insurance for MAT works the same as coverage for any other treatment services. When you are referred for MAT treatment, your coverage will be verified.

Health insurance that covers substance abuse typically pays for any MAT services that are considered medically necessary. Most insurance plans offer at least partial coverage for addiction treatment, including MAT.