Office Visit

EmblemHealth is required to respond to a Contract Level RADV Audit for Payment Year 2019.  

Our vendor, Cognisight, Inc., is contacting health care providers who are part of the Risk Adjustment and Data Validation (RADV) audit sample. Cognisight is asking providers to submit the complete medical record for specific patients for dates of service between Jan. 1, 2018, and Dec. 31, 2018.  

Providers who have not yet supplied the requested records to Cognisight will also be contacted by an EmblemHealth representative to secure the charts.

Please note that a member authorization is not required to release the medical records based on the business associate agreement between EmblemHealth and Cognisight.  

When you receive a request from Cognisight or from EmblemHealth directly, we ask that you respond promptly and submit the required documentation using one of the secure delivery methods detailed in the communication materials. 

Providers who work with a vendor to manage medical records are encouraged to notify their service suppliers now so that responses to Cognisight’s requests can be issued timely.

Through an innovative partnership between EmblemHealth and Dr. Dean Ornish, a preeminent physician and researcher, EmblemHealth launched a first-of-its-kind program for patients who have early-stage Alzheimer’s disease. 

EmblemHealth will be the first health insurer to cover Dr. Ornish’s lifestyle medicine program that enhances brain health and provides crucial support for caregivers.

Karen Ignagni, executive chair and Dr. Dan Knecht, chief medical officer of EmblemHealth, recently discussed the launch of the program in an episode of the Becker’s Payer Issues Podcast. Listen as they explore how evidence-based interventions, community support, and integrated care are reshaping brain health and advancing equity in underserved populations.

Enrollees can also receive helpful resources from EmblemHealth Neighborhood Care.

Eligibility criteria for this program include ages 45 to 90 years, current diagnosis of mild cognitive impairment or early dementia, and a Montreal Cognitive Assessment (MoCA) score of 18 to 26. If you have an EmblemHealth member who you think may qualify, please email  lifestylemedicine@emblemhealth.com or call 646-447-2055 from 9 a.m. to 5 p.m., Monday through Friday.

Starting Sept. 1, 2025, DentaQuest, a leader in dental benefits management, began managing dental services for EmblemHealth members for certain dental products.

With this transition, members will have access to care from an extensive network of over 3,600 dental providers and specialists.

In addition, DentaQuest will offer comprehensive support services to members to ensure they receive high-quality and affordable dental care.

The link between oral and overall health is well-documented, and providers should encourage routine dental visits.

• No referral is required to see a dental provider.
• Inform your patients of the link between oral health and overall health.
• Encourage routine visits beginning as early as age one or first tooth eruption.

Members and providers can visit emblemhealth.com and use our Find-a-Doctor tool to find an in-network dental provider. 

Each year in the United States, about 270,000 women get breast cancer* and 42,000 women die from the disease . Most breast cancers are found in women who are 50 years of age or older, but breast cancer also affects younger women. About one out of every 100 breast cancers diagnosed in the United States is found in a man.

The U.S. Preventive Services Task Force recommends women get their annual mammogram starting at age 40.  We encourage you to talk to your patients between the ages of 40 and 49 about when to start annual screening and how often they should get a mammogram. 

Here are some tips to help increase breast cancer screening compliance:

• Women age 50 to 54 years should be screened with a mammography annually.
• For women age 55 years and older, screening with a mammography is recommended once every two years for those with normal risk or once a year for those with increased risk.
• Have your staff chart-prep and flag patients that need an annual screening order placed during their visit.
• Help boost compliance by offering your patients a “standing order” for their annual screening mammogram, allowing them to complete the screening mammogram before their annual visit with you.

To help you make sure your records meet standards for the HEDIS measure, we will share tips for properly documenting breast cancer screenings in next month’s newsletter. To ensure accurate data capture, when ordering a screening, have your provider credentials co-located with the correct ICD-10 code(s). 

 Here are six ways to help raise breast cancer awareness at your office: 

• Wear pink ribbons. In celebration of breast cancer awareness month, give out pink ribbons to everyone at the office.
• Volunteer together. 
• Shop pink items and show support. 
• Have a pink car wash as a fundraiser.
• Add pink to your office. 
• Have a pink potluck lunch.

Additional resources for providers and members can be found at cdc.gov and at komen.org. Also see recommendations for breast cancer screening. 

As of April 1, 2025, EmblemHealth covers doula services in hospital, clinic, and community settings for Medicaid, Health and Recovery Plan (HARP), VIP Dual Enhanced (HMO D-SNP), and Essential Plan members who are pregnant, birthing, and postpartum (for up to 12 months after the delivery date).

EmblemHealth is inviting doulas to join our provider network. We created Frequently Asked Questions and a training video exclusively for doula providers to help doulas do business with us. 

Please contact medicaidproduct@emblemhealth.com for more information on partnering with us. Billing and coding guidance can be found in the Doula Services Benefit Policy Manual. For more information, see New York State doula services benefit.

Providers must notify Medicaid of any change of address, telephone number, or other pertinent information within 15 days of the change. For more information on this requirement and how to submit changes, see Reminder: Keep Your Directory Data Current.

View the latest Medicaid Updates from the New York State Department of Health.

If you need help navigating our provider portals, please see our videos, quick guides, and Frequently Asked Questions pages: 

• EmblemHealth Videos and Guides.
  • Updated: Search For Preauthorizations
• EmblemHealth Frequently Asked Questions.
• ConnectiCare Videos and Guides.
• ConnectiCare Frequently Asked Questions.

If you still have questions or need additional support, contact Provider Customer Service using the provider portal’s Message Center or live agent chat.

EmblemHealth works with Veradigm to offer free monthly webinars to help educate providers on best practices for the risk adjustment process. This includes accurate medical record documentation and claims coding to capture the complete health status of each patient.

The Veradigm webinars are held on Tuesdays and Thursdays; one in the morning and one in the afternoon. View topics and dates here. Click the Register button, then the Public Event List link, and search by webinar date or title of interest.

Here are the upcoming topics:

•  Sept. 23/25: Making Connections: Proper Coding and Documentation for Neurological Conditions 
• Oct. 28/30: Arm Yourself: Battling Through Coding and Documentation for Cancer

EmblemHealth also works with Veradigm to promote risk adjustment and gap-closure education for primary care providers caring for EmblemHealth members enrolled in these products:

• NY State of Health plans.
• Medicare HMO.
• Medicaid.

If you have any questions, or you would like to set up a private session for your practice, please email Veradigm at providerengagement@veradigm.com or call Veradigm's Customer Support team at 410-928-4218, option 7, from 8 a.m. to 8 p.m., Monday through Friday.

We recommend that you take advantage of the training opportunities offered by CMS’ Medicare Learning Network and eMedNY.