Office Visit

In response to feedback from provider portal users, we made a few adjustments to the new workflow for saving draft preauthorization requests and emergent inpatient admission notifications.

Time Frame Change: Drafts Will Be Saved For 120 Hours

We will be expanding the time frame for saving draft preauthorization requests and emergent inpatient admission notifications to 120 hours.

Enter The NPI When Searching For Drafts

On the Incomplete Preauthorization Requests & Emergent Inpatient Admission Notifications screen, we added a field to enter the requesting or servicing provider’s/facility’s NPI to narrow down the number of drafts shown.

Expanded Provider Search

We expanded the provider search within the Preauthorization Requests and Emergent Inpatient Admission Notifications by lifting the requirement that the user and provider be linked under the same tax ID. This will help our ancillary providers submit requests for their services on behalf of a doctor or other practitioner.

Don’t Forget to Hit Submit

We noticed that some providers enter all the required information for a request/notice, but then do not actually submit the request/notice. You MUST click the Submit button on the bottom of the MCG screen to send us your request/notice.

Select The Correct Category and Sub-Category for Grievances and Appeals

To help us get your grievance or appeal to the right staff faster, look up the specific claim or preauthorization request you wish to dispute on the provider portal. On the Claims Details page or the Preauthorization Details page, use the Ask a Question button to create a message. Be sure to select the following:

Category: Grievance and Appeals

Sub-Category: Post Service Appeal

You can look up a claim and use the Ask a Question feature on the Claims Details page to:

• Request claims status.
• File a grievance; a claims dispute that does not involve a medical necessity decision.
• Respond to a claims denial request to submit records or other supporting documentation.

Note: The provider portal cannot accept corrected claims.

The EmblemHealth Access, Availability, and After-Hours Coverage Standards are monitored using random audits. We want you to pass if you are selected for one. It’s important to us that our members get the care they need in a timely manner.

One common mistake providers make is not adhering to the office waiting time standard. Members with appointments should be seen within 15 minutes, but no later than 30 minutes, of their scheduled appointment time or arrival time, whichever is later. If a delay is unavoidable, the member should be informed and offered alternatives.

Please take the time to periodically review the standards and make sure all staff who answer your phone and schedule appointments have a copy of — and are familiar with — those standards and requirements for scheduling patient appointments.

ConnectiCare | EmblemHealth

Teaching your patients with diabetes how to control their blood sugar is the best way to help them manage their condition and improve their health. EmblemHealth recently launched a diabetes program in the Bronx, just in time for Diabetes Awareness Month in November.

According to the Centers for Disease Control and Prevention (CDC), diabetes is number three on the list of top chronic conditions in the United States after cancer and heart disease. The American Diabetes Association (ADA) has provided the following preventive care recommendations for people living with diabetes:

• Regular A1C testing.
• Kidney function testing.
• Ankle-brachial index.
• Annual retinal eye exam.
• Cholesterol and triglycerides testing.
• Blood pressure testing.

For additional information and resources, please see online information about our diabetes program in The Bronx and the ADA’s Health Checks for People with Diabetes and diabetesjournals.org.

For more information and assistance with coding guidance for quality gap-in-care closure, please visit our Quality Improvement website and download the EmblemHealth and ConnectiCare Quality Measure Resource Guide.

Lung cancer is the leading cause of cancer deaths in America, according to the American Cancer Society. The average age of people when diagnosed is about 70.

Nov. 9 is National Lung Cancer Screening Day. Screening can detect lung cancer early, when it is more likely to be curable. According to the American Lung Association, if lung cancer is caught before it spreads, the likelihood of surviving five years or more is 63%.

The American Cancer Society and U.S. Preventive Services Task Force recommend yearly lung cancer screening with a low-dose CT scan (LDCT) for current and former heavy smokers ages 50 and older.

WellSpark Health’s broad range of well-being resources are helping our members achieve positive behavioral and lifestyle changes. One member, a 35-year-old male coping with Type 2 diabetes and hypertension, joined the monthly 15-minute WellSpark mindfulness sessions and discovered the benefits of taking time to focus on stress management. “I learned that I don't need a lot of time to practice mindfulness. Even 15 minutes can make a big difference in how I feel.”

To see which of our 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.

On Sept. 26, 2024, EmblemHealth Neighborhood Care hosted a panel discussion at our Elmhurst location as part of a chronic disease management resource day.

Nicholas Montedoro, government affairs associate for EmblemHealth, guided the discussion with expert panelists: Ruth Greenfield, registered dietitian for EmblemHealth; Dr. Binh Lam, medical office medical director for AdvantageCare Physicians (ACPNY); Dr. Bindu Babu, senior clinical programming & policy advisor for the NYC Department of Health and Mental Hygiene; and Julianne Roman, associate director of community partnerships for the American Cancer Society. New York City Mayor Eric Adams provided opening remarks. We recommend watching the video of the event and sharing it with your patients.

This event was open to the public and included no-cost blood pressure screenings, health and wellness classes, a mobile farmers market, a produce giveaway, and a cooking demonstration in English and Spanish in honor of Hispanic Heritage Month. Community partners also provided additional education and resources.

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 and ConnectiCare provider manuals are valuable online resources and an extension of your Provider Agreements. You can find the manuals in the top navigation menus of our provider websites, EmblemHealth | ConnectiCare.

The manuals apply to all 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.

Key resources include Access & Availability Standards for EmblemHealth and ConnectiCare which set up the expected time frames for appointment availability, appointment wait times, and after hours coverage.

Here are links to the most recent updates:

• Member Policies and Rights updated with changes to the nondiscrimination section and new information about Reproductive Health Care Privacy.
• Provider Networks and Member Benefit Plans updated with new information for Permanent Placement in Nursing Homes.
• Updated list of Health Homes participating in the Enhanced Care Prime Network.