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Provider Portal Offers Convenient New Features
We have successfully moved all EmblemHealth and ConnectiCare provider portal users to our new, more modern portals. Thank you for your cooperation during the transition. Both portals (EmblemHealth and ConnectiCare) have these key features to help us better work together:
Referrals Need Both Referring and Servicing Providers
Providers must make referrals for plans that require them through our portals. The new transaction requires the selection of the Referring Provider and then the Servicing Provider.
Preauthorization Requests – Time-Saving Features
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Portal users can upload documents in support of preauthorization requests. To streamline workflow, we invite you to upload documents to the portal instead of faxing them. You can do this when the request is created, or later.
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The Preauthorization Check Tool covers all our members. This feature will indicate if a service needs preauthorization and who to work with.
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Portal Accounts and Access to Transactions
Your designated provider Portal Administrators/Office Managers (Administrator) have been empowered to set up user accounts and manage user roles and permissions. This is in support of HIPAA compliance. If you need a new account or need to adjust your access to portal transactions (e.g. create a referral or look up a claim), your administrator must do that for you. Help is available to your Administrator, but our Provider Customer Service teams can no longer set up individual accounts or change security access.
Still Need Help?
We posted robust educational materials that walk you through a range of topics from signing in to completing a transaction. If you get stuck anywhere in the process, help is available. First, look for an answer in our Frequently Asked Questions:
EmblemHealth FAQs
ConnectiCare FAQs
If you still have questions or need additional support, you may contact Provider Customer Service:
EmblemHealth: 866-447-9717
ConnectiCare: Commercial: 860-674-5850, Medicare: 877-224-8230
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Provider ID Numbers to be Retired for ConnectiCare and EmblemHealth
As part of our continuing efforts to simplify processes for you, we are retiring our provider identification numbers. The Amisys ID for ConnectiCare and the HIP PRIS # and GHI Provider Number for EmblemHealth (legacy numbers), are no longer needed. Further, you will no longer need to use a company-issued ID number. You should see little impact from this change as our new portals use NPI and TIN numbers for transactions.
The legacy numbers now only appear in our provider directories. Later this year, directory IDs will be replaced with a “PRPR ID” number used in our claims system. Your patients will need these numbers when selecting a primary care provider.
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ConnectiCare Recognized by Mental Health CT
In July, Mental Health CT presented ConnectiCare President Eric Galvin with a handcrafted tiki to recognize ConnectiCare’s support during their 31 Days of Wellness campaign in May. The campaign exceeded their original goal of $31,000, bringing the campaign total to over $72,000 with ConnectiCare’s matching donation. Eric Galvin is pictured second from right in the photo (Facebook link).
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City of New York Offers Medicare Advantage Option in 2022
The City of New York has awarded their group retiree business to Retiree Health Alliance, an alliance between EmblemHealth and Empire Blue Cross Blue Shield (BCBS). Effective Jan. 1, 2022, approximately 240,000 Medicare-eligible City of New York retirees will transition to Retiree Health Alliance’s NYC Medicare Advantage Plus plan.
The NYC Medicare Advantage Plus plan is a Medicare Advantage PPO plan that allows retirees to receive services from both in-network and out-of-network providers. Out-of-network providers must be eligible to receive Medicare payments. Under this new plan, City of New York retirees will have no difference in cost-share for both in-network and out-of-network services. NYC Medicare Advantage Plus offers the same hospital and medical benefits Medicare covers, as well as additional benefits Medicare does not provide such as an annual routine physical exam, hearing, health and fitness tracker LiveHealth Online, and SilverSneakers®.
In the coming months, provider education materials and training opportunities – specific to the NYC Medicare Advantage Plus plan – will be made available to all providers in both EmblemHealth’s and Empire’s Medicare Advantage networks. We look forward to partnering with the City of New York and Empire BCBS to improve the health of New Yorkers through this opportunity.
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EmblemHealth Risk Adjustment Program for PCPs Continues
EmblemHealth continues to partner with Pulse8™ to promote risk adjustment education and gap closure efforts for our New York State of Health (NYSOH) Marketplace, Medicare HMO and Medicaid members. The process of risk adjustment relies on providers’ accurate medical record documentation and claims coding to capture the complete health status of each patient. To help you do this, Pulse8 is offering free, 60-minute monthly webinars that are followed by a question-and-answer period. We encourage you and your staff to participate. Learn more about Pulse8 and how it can help your practice. You may register for Pulse8’s monthly webinars through the secure provider portal or on our website.
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September is Gynecologic Cancer Awareness Month
According to the Centers for Disease Control and Prevention (CDC), all women are at risk for gynecologic cancers. Talk to your patients and encourage them to visit their gynecologist and get regular screenings. Cervical Cancer Screening is one of several quality measures we monitor for women’s health. See our Provider Quality Measure Resource Guide for this and other measures that affect your patients. The CDC offers online resources and continuing medical education (CME) training for health care providers.
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COMMERICAL BUSINESS UPDATE
Fully Insured EmblemHealth Members Moving to Bridge Program
As of Aug. 1, 2021, several of our current large groups with EmblemHealth Plan, Inc. are leveraging our Bridge Program. As part of the program, members will be able to see their current providers, and those in four other networks, as an alternative to the current single-network access.
See our dedicated Bridge webpage to learn more about the program and which administrative guidelines to follow. All plans will continue to follow the same Bridge Program payment protocols.
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GOVERNMENT-SPONSORED PROGRAM UPDATES
MEDICARE
2021 Annual Special Needs Plan Model of Care Training
The Centers for Medicare & Medicaid Services (CMS) requires providers to complete training for each dual-eligible special needs plan (D-SNP) they participate in. Our trainings take only 15 minutes to complete. Providers must submit an attestation to receive a certificate of completion.
ConnectiCare’s Training Deadline: Aug. 31, 2021
Providers who care for ConnectiCare’s Medicare Advantage members with Choice Dual (HMO D-SNP) plans need to complete ConnectiCare’s Special Needs Plan Model of Care (SNP MOC) training no later than Aug. 31.
EmblemHealth’s Training Deadline: Oct. 31, 2021
By Oct. 31, EmblemHealth’s VIP Bold Network and Reserve Network providers must complete the 2021 EmblemHealth SNP MOC annual provider training and providers in the Network Access Network must complete training offered by ArchCare.
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Commercial and Medicare Preventive Grid Updates
Our commercial Guides to Preventive Health Services have been updated with changes effective Oct. 1, 2021. Our Medicare guides were updated Jan. 1, 2021 to align with CMS. View the new versions:
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Reimbursement Policies
CODING
We follow the correct coding rules established by the Centers for Disease Control, American Medical Association, National Uniform Billing Committee, and Centers for Medicare and Medicaid Services for both professional and facility claims.
Starting Nov. 16, 2021, EmblemHealth’s Coding Edit Rules are being updated to include facility claims. Note: Capped Durable Medical Equipment (DME) rentals for EmblemHealth and ConnectiCare will be denied when billed without modifiers KH, KI or KJ. This DME change applies to Medicare claims only.
Correct coding reminder: Providers seeing Medicare patients for an annual well women exam should use code G0101 for dates of service on or after Jan. 1, 2020.
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Medical Policy Updates
All EmblemHealth and ConnectiCare Medical Policies are available for download from our provider websites. The following are the recently revised policies for EmblemHealth:
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Blepharoplasty
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Breast Reduction Mammoplasty
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Capsule Endoscopy
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Visual Electrophysiology Testing
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The following are the recently revised policies for ConnectiCare:
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Blepharoplasty
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Breast Reduction Mammoplasty – Medical criteria used by ConnectiCare have been retired in favor of EmblemHealth’s criteria. Going forward, there will be a single policy for all members.
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Visual Electrophysiology Testing
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ConnectiCare is a brand name used for products and services provided by ConnectiCare Insurance Company Inc. and its affiliates, members of the EmblemHealth family of companies.
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