Hard-copy forms can be requested by calling the U.S. Government Publishing Office at 800-869-6590 or 202-512-1800. 2020 EmblemHealth. Policies and procedures for the coordinated care of our members. You can manage your learning, track credits online, and complete activities at your own pace. Our Companies, Lines of Business, Networks, and Benefit Plans (PDF), Medicaid, HARP, and CHPlus (State-Sponsored Programs), Cultural Competency Continuing Education and Resources, Medicaid Cultural Competency Certification, Find a center near you, view classes and events, and more, EmblemHealth Neighborhood Care Physician Referral Form (PDF), Vendor-Managed Utilization Management Programs, Physical and Occupational Therapy Program, Radiology-Related Programs and Privileging Rules for Non-Radiologists, New Century Health Medical Oncology Policies, UM and Medical Management Pharmacy Services, COVID-19 Updates and Key Information You Need to Know, EmblemHealth Guide for Electronic Claims Submissions, Payment processes unique to our health plans, EmblemHealth Guide for NPIs and Taxonomy Codes, 2022 Provider Networks and Member Benefit Plans, EmblemHealth Spine Surgery and Pain Management Therapies Program, Outpatient Diagnostic Imaging Privileging, Benefits to Participation in Dental Network, emblemhealth.com/providers/manual/credentialing, emblemhealth.com/providers/manual/member-policies-andrights, emblemhealth.com/providers/manual/pharmacy-services, emblemhealth.com/providers/manual/care-management, emblemhealth.com/providers/resources/provider-sign-in, emblemhealth.com/providers/manual/behavioral-health-services, 2023 Summary of Companies, Lines of Business, Networks, and Benefit Plans, 2023 Benefit Plans That Do Not Require a Referral, EmblemHealths Current List of Network Labs, Improving the Patient Experience, Timely Access to Care, and Continuous Quality Improvement, Access, Availability & After Hours Standards, Consumer Assessment of Healthcare Providers and Systems (CAHPS) Provider Tip Sheet, Improving the Patient Experience: Information and Tips to Enhance Patient Interactions, Quality Measures and Risk Adjustment Telehealth Tip Sheet, Reference Guide to Early Screenings and Follow-Up for Pediatric Health Care Providers, Behavioral Health: Mental Health & Substance Abuse, Behavorial Health Clinical Practice Guidelines, Childrens Medicaid Health and Behavioral Health System Transformation, Center for Practice Innovations (CPI) Learning Community, National Provider Identifier (NPI)and Taxonomy Code(s), Pulse8 Risk Adjustment frequently asked questions, Preauthorization Rules (current code lists and notable changes), Quality Improvement (programs and resources, Pharmacy (formularies, policies, preauthorization lists, utilization management programs), Behavioral Health (guidelines and resources), EmblemHealths Clinical Practice Guidelines, New Century HealthMedical Oncology Policies, Optum Emergency Department Claim (EDC) Analyzer tool, Learning Online: Required Training and Educational Opportunities for Medical Providers, EmblemHealths 2023 Formulary Updates webpage. Not only can you look up individual claims, but you can download the last 24 months of claims information up to 10,000 records at a time! Pri-Medoffers courses such as HIV update for the non-ID specialist: What every clinician needs to know and Pre-exposure prophylaxis for HIV Infection. Just search for HIV to find them. 2020 EmblemHealth. Here is a sampling of what you can find there: Free Pulse8 Webinars for Patient Management and ICD-10 Coding. Additional support:We offer aTransitions of Care programto help members with complex care issues better manage their health after a hospital admission. Box 1850 Hicksville, NY . EmblemHealth and Connecticares Care Management programs can assist providers by helping navigate our delivery systems and coordinate care across care settings to ensure our members can get the necessary care and resources in the right setting. . InstaMed FAQs. SOMOS CMS-1500 Claim Form. Teletypewriter (TTY/TDD) services can be reached by calling 711. To register, go to pulse8.zoom.us and select the session that interests you. The main call center switchboard will then route your call to the appropriate area. Below, find the new and revised EmblemHealth medical policies published since December2021 as well as those that have been retired. Many EmblemHealth and ConnectiCare members have plans which give them access to providers in both organizations. We also expect our members to respect you and to honor their responsibilities. Instead of calling for claims' status, you can quickly find the information on our provider portal. Contact Customer Service by Phone EmblemHealth: 866-447-9717 EmblemHealth Plan, Inc. (formerly GHI) 212-501-4444 in New York City 800-624-2414 outside of New York City Medicare PPO 866-557-7300 Medicare HMO 866-447-9717 EmblemHealth Plan, Inc. (formerly GHI) HMO 877-244-4466 HIP A member's experience often begins with their use of our provider directories. It is not medical advice and should not be substituted for regular consultation with your health care provider. New In-House Post-Acute Care Process Coming. You may receive timeouts on your 271 and 277 response transactions. Inquire About Your EmblemHealth Claim Status: You can check on the status of your EmblemHealth claim by logging in to your online account at http://www.emblemhealth.com/Members. To refer a member to one of our Care/Case Management programs: EmblemHealth: See ourCare Management Programspage for program descriptions, ways we can support you and your patients, and program-specific contact information. Below, find the new and revised medical policies published since December 2021, including a new policy starting January 1, 2023: To bring more transparency to how we process claims, we introduced two new payment integrity policies: We follow the correct coding rules established by the Centers for Disease Control and Prevention, American Medical Association, National Uniform Billing Committee, and Centers for Medicare & Medicaid Services for both professional and facility claims. We are committed to identifying ways to reduce time spent on administrative transactions. The proper coding of procedure and diagnosis for billing purposes. EmblemHealth Contact Information Customer Service is available seven days a week (excluding major holidays), 8 am to 8 pm. Make sure your staff is assigned to the Tax IDs, providers, and roles that match their jobs required access to conform with HIPAAs minimally necessary standards. Extended hours, including weekends at some locations. Tell Us What You Think! Claims Contacts For Claims Contacts please go here Who to Contact for Preauthorization For Preauthorization Contacts, please go here. The report will be created and delivered to the Documents section for pickup. Those who follow established guidelines and best practices are successfully increasing quality measure scores and patient satisfaction. Miss any of our emails? For a list of frequently used phone numbers, addresses, and websites, see the Directory chapter of the EmblemHealth Provider Manual. Most recently, we added an easy Check Provider Network Status look-up tool for you to see if you are in-network for a member. ECHO Health, Inc. facilitates claims payments for EmblemHealth. Find the specific content you are looking for from our extensive Provider Manual. The Toolkit is where we house welcome materials for new providers. New York Cancer & Blood Specialists (NYCBS) A Concierge Experience. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you need to file a claim personally, contact the member services department at 1-877-842-3625. New Aug. 1, 2022: Commercial Plan Site of Service Coverage Rules for Maintenance Infusions. EmblemHealth 55 Water Street New York, NY 10041-8190 Provider Services is available 8 a.m. to 6 p.m., Monday to Friday. To file a claim you must fill out a claim form, located at http://www.emblemhealth.com/Members/Forms.aspx, and send the claim form to the address on the back of your member card. Our 2023 Summary of Companies, Lines of Business, Networks, and Benefit Plans is an extension of our provider agreement(s). EmblemHealth was established more than 75 years ago. Required fields are marked *. VisitECHO, click the Click Here button, and follow the instructions to enroll. Site of Service Medical Policy Infusions and Injectables. Billing Specialists: Use Our Portal to Simplify Accounts Receivables for EmblemHealth Members, Medicaid, HARP, and CHPlus (State-Sponsored Programs). Providers without an account can register quickly by clicking here. Authorizations from Express Scripts company Care Continuum given prior to Aug. 1, 2022, are being honored through the date noted in theirapproval letter. To contact the appropriate area by phone, first review the division/topics of interest menu below. Official Website: The official website for EmblemHealth is located at http://www.emblemhealth.com. We partner withBeacon Health Optionsto provide and to manage mental health and substance use services. Use the Provider Portal for Preauthorization, Concurrent Review, Referral, and ER Admission/Notification Transactions. Not only can you look up individual claims, but you can download the last 24 months of claims information - up to 10,000 records at a time! If you are seeking employment at CenterLight, please call our Human Resources job hotline . The online Provider Manual is an extension of your EmblemHealth or ConnectiCare contract. We strive to simultaneously improve the health status of our members, improve each members experience of care, and reduce the per capita cost of health care. Note:eviCore will continue to handle durable medical equipment for EmblemHealth members. Applicants must apply at a local government office for Medicaid insurance. The Preauthorization Check Tool returns information for all EmblemHealth and ConnectiCare members. Schedule time to periodically audit your portal users. Sign in to yourProvider/PracticeProfile to make sure you have the right National Provider Identifier (NPI)and Taxonomy Code(s)on file. We started sending emails to let you know about key provider portal transactions and how they can make things easier for you. See Care Plans Training Guide and Video. You may use telehealth/virtual care to close gaps in care. Contact Us|Privacy Policy|Terms of Service. Upcoming webinars:To help you better understand howthe insourcing of all PAC services and the Transitions of Care programaffects the members in your care,we will host a series of informational webinars. The Provider Toolkit has guides and quick references to help with the administration of our plans. Please review and share the following materials with your clinicians and staff. Even better, you have access to Downloadable Claim Reports. Be sure to check theClaims Cornersection of our provider website frequentlyfor the latest updates. SOMOS Innovation Program FAQs. Here are some of the most visited sections within the Provider Manual: *Members assigned to Montefiore CMO, HealthCare Partners, and SOMOS will continue to follow their administrative processes and will need to submit ER admission/newborn notifications directly to them. Box 1701 New York, NY 10023. * This year, we focused on improving the provider portal to simplify navigation and get you the information you need faster. Time is money. To refer a patient to the EmblemHealthHIV Case Management program, please call or have the member call800-447-0768. See the Clinical Corner section below for other provider portal improvements. 2020 EmblemHealth. Deactivate portal accounts for staff* who have left your organization. All Rights Reserved. StartingAug. 1, 2022,in support of our commitment to keeping members costs down, we changed how we coverongoingmaintenanceinfusion services for adults (21+) in our commercial plans for both EmblemHealth and ConnectiCare. Mail paper claims to: EmblemHealth Behavioral Health Claim Services P.O. EmblemHealth also works as a Medicaid provider in some states. Program informationis available to our members on the Live Well section of our member website. Before the end of 2022, EmblemHealth will begin to manage post-acute care (PAC) for EmblemHealth members, replacingeviCore. Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. You can save time by checking Provider Help and Support page's compilation of frequently asked questions and answers before contacting Customer Service. Refer to this list of 2023 Benefit Plans That Do Not Require a Referral when scheduling appointments so you do not spend time creating or searching for referrals that are not needed. Still dont have a portal account or need help managing one? Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage. To satisfy this requirement, providers must complete one of these two programs: The Claims Corner section of our provider website is part of the EmblemHealth Provider Manual and houses Administrative Guidelines described in our participation agreements. For full details, please seethe Site of Service Medical Policy Infusions and Injectables. For a list of government agencies with required reporting, read theRegulatory Mandatory Reporting chapterof our online Provider Manual. Timely Submission Participating Providers: EmblemHealth Neighborhood Care provides in-person customer support, access to community resources, and programming to help the community learn healthy behaviors. Visit our EmblemHealth Preauthorization Lists page to see what requires preauthorization and who is responsible for the utilization review. Our network practitioners are required to participate in government reporting procedures and adhere to all rules, regulations, and codes. As always, visit our Provider Manual for guidance and reference on regulatory, policy, and accreditation requirements (such as provider rights, member rights and responsibilities, availability of criteria, and pharmacy procedures). Thislisting also captures annual procedure coding updates since December 2021. We have adopted the Institute forHealthcare Improvement (IHI) and the Centers for Medicare & Medicaid Services (CMS) Triple-Aim for Healthcare Improvement. ConnectiCares Medical Policies are posted on the Medical Coverage Criteria page. Our Companies, Lines of Business, Networks, and Benefit Plans (PDF), Medicaid, HARP, and CHPlus (State-Sponsored Programs), Cultural Competency Continuing Education and Resources, Medicaid Cultural Competency Certification, Find a center near you, view classes and events, and more, EmblemHealth Neighborhood Care Physician Referral Form (PDF), Vendor-Managed Utilization Management Programs, Physical and Occupational Therapy Program, Radiology-Related Programs and Privileging Rules for Non-Radiologists, New Century Health Medical Oncology Policies, UM and Medical Management Pharmacy Services, COVID-19 Updates and Key Information You Need to Know, EmblemHealth Guide for Electronic Claims Submissions, Payment processes unique to our health plans, EmblemHealth Guide for NPIs and Taxonomy Codes, 2022 Provider Networks and Member Benefit Plans, EmblemHealth Spine Surgery and Pain Management Therapies Program, Outpatient Diagnostic Imaging Privileging, Benefits to Participation in Dental Network, Duplicate Claims from a Non-Physician Practitioner, Prescribing eHealth Initiative Best Practices and Guidance. Any information provided on this Website is for informational purposes only. SOMOS Prior Authorization Form (Behavioral Health) SOMOS Prior Authorization Form (Medical) SOMOS UB-04 Medical Claim Form. Toll-free: 800-421-2408. The New York State Department of Health, AIDS Institute has lead responsibility for coordinating state programs, services, and activities relating to HIV/AIDS, sexually transmitted diseases (STDs), and hepatitis C. For information on programs, initiatives and services, visit theAIDS Institutefor training and resources to help your patients. We also added Care Plans for most members who participate in our Care/Case Management programs. To see announcements of formulary changes, see EmblemHealths 2023 Formulary Updates webpage. Manner, free from discrimination, and Essential plan members portal access since December 2021 on paper, please here! 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