Do Not Bill Members with Full Medicaid or QMB

If Medicare-Medicaid dual eligible individuals have their Part A and Part B cost-share fully covered by their Medicaid plan, or are Qualified Medicare Beneficiaries (QMBs), they are not responsible for their Medicare Advantage cost-share for covered services. Please do not balance bill these members for any other costs. Any Medicare and Medicaid payments for services given to these members must be accepted as payment in full.

For EmblemHealth members, you can use ePACES to check whether the member has full or partial Medicaid benefits. For more detail, see our 2021 Medicare Advantage Guide.

For ConnectiCare members, you can contact the Connecticut Department of Social Services at 800-842-8440 or visit their website.

Medicare Outpatient Observation Notice (MOON)

All hospitals and critical access hospitals are required by CMS to provide Medicare beneficiaries, including Medicare Advantage enrollees, with the OMB-approved Medicare Outpatient Observation Notice (MOON). The MOON and instructions for completing it are available on CMS’ website.

POLICIES, BILLING AND CLAIMS

The ConnectiCare website is a rich source of information that helps your practice navigate ConnectiCare claims and billing processes. Check the website often to see new postings. Similar information can be found on EmblemHealth’s website.

Payment Reimbursement Policies
New Policy for Commercial Members in 2022: No Cost/Reduced Cost Drugs, Implants & Devices

Starting Jan. 1, 2022, the No Cost/Reduced Cost Drugs, Implants & Devices Reimbursement Policy will be applied to both inpatient and outpatient hospital services for both EmblemHealth and ConnectiCare commercial members in the same way that we have been processing Medicare claims since Jan. 1, 2020. This policy has coding guidelines for reporting drugs, devices, and/or implants with their associated procedures when obtained by the provider at full cost, no cost, or at a reduced cost.

Policy Updates

The following policies have been updated and published in their respective Reimbursement Policies tables:

Same Policies: New Names, Formats, or Locations
The following polices have not changed. They have recently been reviewed and may have been documented in a new format, renamed, and/or added to the following table(s):

EmblemHealth Reimbursement Polices table:

ConnectiCare’s Reimbursement Polices tables:

Reminder: Enhanced Clinical Editing Processes – Post-Payment Reviews Have Begun
Starting on Sept. 1, 2021, Cotiviti, Inc. began periodic post-payment reviews of EmblemHealth’s paid medical claims. The post-payment reviews to be conducted are: Retrospective Accuracy datamining (RA) and Clinical Claim Validation DRG review (CCV). These are the same/similar reviews that are currently being conducted by Optum on behalf of EmblemHealth. Click here for more information.

CLINICAL CORNER
Home Infusion Utilization Management

Beginning Oct. 1, 2021, Care Continuum (CCUM), an Express Scripts company, will perform home infusion utilization management services for all EmblemHealth and ConnectiCare members. This includes preauthorization of drugs, supplies, and nursing visits for members in all lines of business. To request preauthorization for home infusion, you can contact CCUM from 8 a.m. to 7 p.m. ET, Monday to Friday at the numbers listed below based on the member’s plan.

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:

The following are the recently revised policies for ConnectiCare:

Recent Provider Headlines

Check out recent provider news for ConnectiCare and EmblemHealth.

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