If you do not have computer access, please send changes to our Provider Modifications team: By mail:EmblemHealth, Attn: Provider Modifications, 55 Water Street, New York, NY 10041. For a list of frequently used phone numbers, addresses, and websites, clickhere. Closely followClinical Practice Guidelines. Any information provided on this Website is for informational purposes only. These materials are intended to help prepare new NYS Medicaid Childrens providers for the transition to Medicaid Managed Care. It is not medical advice and should not be substituted for regular consultation with your health care provider. Educate your patients on the importance of preventive services. Bill with appropriate Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System(HCPCS), and International Classification of Diseases (ICD) codes. follow-up care for members with co-existing medical and behavioral health disorders. The Consumer Assessment of Healthcare Providers and Systems (CAHPS)* and Enrollee Experience surveys are annual surveys used to measure patients experiences with the health plan, and access to their doctors and doctors offices. follow-up care for members with coexisting medical and behavioral health disorders. We provide condition-specific education to reinforce established treatment plans and ensure a thoughtful, member-centric experience to achieve their self-management goals. Members managed by HealthCare Partners and Montefiore CMS are exempt from these programs and will medically manage their own assigned membership. Be sure to check theClaims Cornersection of our provider website frequentlyfor the latest updates. We have adopted a model of Continuous Quality Improvement in medical, pharmaceutical, dental, behavioral health care, and service provided to a complex, culturally and language-diverse membership as a core business strategy. Implement a prevention program for behavioral disorders commonly managed in the primary care setting. We can also assist in navigation and coordination support to ensure our members can obtain the necessary care and resources in the right setting. If your application was credentialed directly by EmblemHealths staff, review and make changes to your profile bysigning into your account. Here are some steps as a doctor you can take to help members remain adherent: Starting Jan. 1, 2022, many of our plans will offer generic drugs (Tier 1 and Tier 2) for $0 copay for members who get their refills through Express Scripts Preferred Mail Order pharmacy. The New York State Office of Mental Health (OMH), the Office of Alcoholism and Substance Abuse Services (OASAS), and the New York State Department of Health (NYSDOH) require EmblemHealths behavioral health providers to complete State-approved cultural competence training on an annual basis. Grievances and Appeals Spend less time on the phone and feeding documents into a fax machine. Although the Centers for Medicare & Medicaid Services (CMS) prohibits providers from requesting payment from dual-eligible and QMB members, pharmacies can receive additional payment if they balance bill all applicable Part B items to New York States eMedNY program on their members' behalf. This includes the transition to Medicaid Managed Care, the new Children and Family Treatment and Support Services, and the aligned Home and Community Based Services. This means that the doctor's office has 90 days from February 20th to submit the patient's insurance claim after the patient's visit. For more information, please refer to our Claims Corner article onAvoiding Duplicate Claim Submissions. Implement a prevention program for behavioral disorders commonly managed in the primary care setting. Company ABC has set their timely filing limit to 90 days "after the day of service.". Starting April 1, 2021, we anticipate the NYSDOH will carve out drug coverage from Medicaid Managed Care plans. treatment access. For information, see theNetwork and Benefit Planstab below. Ifyou think a patient is at risk, please let them know there are organizations ready to help. However, we encourage providers to submit claims on a monthly basis. The Toolkit is where we house Welcome materials for new providers. See the Clinical Corner Medical Policies section of this microsite to see 2020 changes. Medical claims can be sent to: Insurance Benefit Administrators, c/o Zelis, Box 247, Alpharetta, GA, 30009-0247; EDI Payor ID: 07689. 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. Revisions are made as policies are renewed, new programs are introduced, and rules change. Dispositions apply to all lines of business unless otherwise indicated. For a list of government agencies with required reporting, access theRegulatory Mandatory Reporting chapterof our online Provider Manual. To learn about EmblemHealth's Bridge Program for 2021, pleaseclick hereto see our updated guide. Those who follow established guidelines and best practices are successfully increasing quality measure scores and patient satisfaction. 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. You can manage your learning, track credits online, and complete activities at your own pace. Improve management of elderly members with indications of depression and multiple behavioral health care medications. New Cancer Drugs Require Preauthorization. You can find this number on your Explanation of Benefits. Our members will be expected to obtain their medication from Medicaid Fee-For-Service participating pharmacies who will submit claims to the State. discussing treatment options for their condition(s) candidly regardless of cost or benefit coverage. Accredo is EmblemHealths specialty pharmacy. Mail Handlers Benefit Plan Timely Filing Limit The claim must submit by December 31 of the year after the year patient received the service unless timely filing was prevented by administrative operations of the Government or legal incapacity. Example: Patient seen on 07/20/2020, file claim by 07. HIV), and behavioral health issues. Remind members to track their refills and make an appointment for a new prescription before they run out. For a list of benefit plans that do not require a referral, clickhere. Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Participating practitioners may not bill the patient for services that EmblemHealth has denied because of late submission. Encourage members to leverage available technologies (medication reminder apps on your phone or tablet, like the Express Scripts mobile app). Use the Claims Timely Filing Calculator to determine the timely filing limit for your service. Fax: (518) 641-3507. Only Prime, which will serve groups,will require referrals. Members tend to share symptoms, concerns, issues, and other needs with their PCPs rather than or before considering professional behavioral health services. The Emblem Behavioral Health Services Program Customer Service phone number (1-888-447-2526) will not change on the cards, but the name of the program and claims address will be updated on reissued ID cards. Talk to members about the importance of taking their medications on time as prescribed. VisitECHO, click on the Click Here button, and follow the instructions to enroll. Corrected GHI EPO/PPO paper claims without this form will be treated as a new claim submission and denied as a duplicate. Reconsideration or Claim Disputes/Appeals: The Consumer Assessment of Healthcare Providers and Systems (CAHPS)*survey is an annual survey used to measure patients experience with the health plan, and access to their doctor and doctors office. Appropriate diagnosis, treatment, and referral of behavioral health disorders commonly seen in primary care. Ensure patients understand timeline for follow-up. Facilitate communication between a medical practitioner and the behavioral health care practitioner who is treating the medical practitioners patient. Following is information to help you meet members' expectations and ways we are measured in meeting them. These include: Practitioners opportunities for collaboration, continuity, and coordination of care: Confidentiality for domestic violence or endangered victims. Our Medical Technologies Database is routinely reviewed to ensure it is current. Wellmark BCBS of Iowa and South Dakota timely filing limit for filing an initial claims: 180 Days from the Date of service. Annually, and as updates become available, providers can access the following in the EmblemHealth Provider Manual Pharmacy Services chapter, which includes the information posted in Clinical Corner: A list of pharmaceuticals including restrictions and preferences. These are the same/similar reviews that are currently being conducted by Optum on behalf of EmblemHealth. To order medications, contact Accredo using accredo.com; or call them at 855-216-2166. ConnectiCare Choice Dual Vista (HMO D-SNP) is a special needs plan for members with full Medicaid and Medicare (Part A and Part B services) coverage that also includes: Providers will need to coordinate the payment for covered services with Connecticuts Medicaid program and cannot balance bill members for any services without prior written notice. If something is not right, please let us know based on how you participate with us: If you work for an organization that is delegated for credentialing, please ask your practice administrator to include the correction on the next dataset submission. Use the teach-back method to ensure understanding. Our online Provider Manual is an extension of your contract with us. 30 days. If you have questions, or would like to set up a private session for your practice, please email ProviderEngagement@Pulse8.com or call their Customer Support team at 410-928-4218 ext 7. 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. Check Claim Status with EZ-Net Many EmblemHealth and ConnectiCare members have plans which give them access to providers in both organizations. Assist in coordination of non-emergency transportation, if necessary. It is the billing providers responsibility to ensure their responses are both prompt and complete. For a listing of domestic violence hotlines by county, go to theNYS Coalition Against Domestic Violence website: New York State Domestic Violence Programs County Listing. 11/13, added to already-covered Medicare), Medtronic MiniMed 670G and 770G monitoring systems*, Myocardial strain imaging (Commercial and Medicaid; added to already-covered Medicare), Nasal endoscopy, surgical; balloon dilation of eustachian tube (E.g., ACCLARENT AERA, Per-oral endoscopic myotomy (POEM) for the treatment of swallowing disorders (e.g., achalasia)Prostate cancer antigen 3 gene (PCA 3) screening for prostate cancer (Progensa, Monarch External Trigeminal Nerve Stimulation [eTNS] System for pediatric attention deficit disorder (ADHD), PIGF Preeclampsia Screen (PerkinElmer Genetics), Patient Specific Talus Spacer 3D-printed talus implant, Cortical Stimulation for Epilepsy (NeuroPace. Performance related to member care is continuously being assessed by accreditation and regulatory agencies. Be sure to include the codes with the most specific definition of the diagnosis, procedure, and/or associated result. You can find this number on your Explanation of Benefits. Please let your affected patients know they are entitled to these privacy protections: Group policy members may ask us to enforce an order of protection against the policyholder or other person. Preauthorization List Reductions and Updates for 2022. Below is a summary of the updates posted. Grievances and Appeals You have the right to file a grievance or complaint and appeal a decision made by us. EmblemHealth Neighborhood Care provides in-person customer support, access to community resources, and programming to help the community learn healthy behaviors. The member must give us a valid order of protection or let us know he/she is a victim of domestic violence and will be in danger by the disclosure of certain information. EmblemHealth and Connecticares Care Management programs provide members with a holistic and seamless clinical model throughout their care journey. According to the NYSDOH, there are providers who are not registered with the Medicaid Fee-For-Service program (FFS Medicaid) who are prescribing medications for EmblemHealth members. EmblemHealth continually conducts activities to improve behavioral health and general medical care, including collaboration with behavioral health practitioners. Appropriate use of psychotropic medications. Experimental, Investigational or Unproven Services Medical Necessity Guidelines, Non-Invasive H Pylori Testing (Commercial), Vertical Expandable Prosthetic Titanium Rib (VEPTR) (Commercial), Vitamin D Deficiency Testing (Commercial), Lung Volume Reduction Surgery (Commercial), Visual Evoked Potential Testing for Pediatric Populations in the Primary Care Setting (Commercial), Intraoperative Neurophysiology Monitoring (IONM) (Commercial and Medicare -, Experimental, Investigational or Unproven Services (Commercial), Experimental, Investigational or Unproven Services (Medicare). The rights and responsibilities include their providers: allowing them to participate in making decisions about their health care. If you have any claims-related questions, please sign in to our secure portal and use the Message Center. Therefore, print quality and data alignment for paper EmblemHealthimplemented claims policy and coding guideline changes over the past year. Notification via letters, their audit findings, and instructions on how to appeal their determinations will be coming directly from Optum. Find our Quality Improvement programs and resources here. If you have any concerns about your health, please contact your health care provider's office. Federal law mandates that health care practitioners use their unique, 10-digit NPI when submitting standard electronic health care transactions, such as claims. The timely filing limit cannot be extended beyond December 31 of the third calendar year after the year in which the services were furnished. TheEmblemHealthtimely filing time frame is120 days from the date of service, unlessEmblemHealthis the secondary payor or the participation agreement states an alternative time frame to be applied. Wellmark Blue Cross Blue Shield timely filing limit - Iowa and South Dakota. Click hereto see the selected preferred products and the step therapy protocols. Improve the process for members to authorize sharing of behavioral health information. Please review and share the materials below with your clinicians and staff. If you have any concerns about your health, please contact your health care provider's office. We changed some policy titles to improve sorting results. EmblemHealths response to COVID-19 has made usmore nimble and resilientas individuals and as a company,with the ability to overcome pandemic-related disruptions. This page offers materials you can give your members in support of your care plans. For full information about our mental health and substance abuse (MHSA) services available to your patients, see theBehavioral Health chapterof the EmblemHealth Provider Manual. Commercial/CHPlus Instead, our role is to help practitioners manage patient care by supporting the practitioner-patient relationship. Childrens Medicaid Health and Behavioral Health System Transformation. Average time for both electronic (EDI) and paper claims to process on a remittance advice (RA). You can now see information and process transactions for all of our members with one User ID! home health aides, who access care through the HIP, an EmblemHealth company. appropriate diagnosis treatment. Find our Quality Improvement programs and resources here. Consider prescribing 90-day supply prescriptions for maintenance medications. * Listed in EH Medical Policy, Insulin Delivery Devices and Continuous Glucose Monitoring Systems, ConnectiCare in 2022 & What You May Have Missed in 2021. It is set by the insurance companies to submit the initial claim for the service rendered. We follow the correct coding rules established by the Centers for Disease Control, American Medical Association, National Uniform Billing Committee, and Centers for Medicare & Medicaid Services for both professional and facility claims. In 2021, SOMOS announced that its members will not require referrals to be seen by specialists. Practitioners shall comply with all applicable laws prohibiting discrimination against any member and in accordance with the same standards and priority as the provider treats his/her/its other patients regardless of any of the following factors: Evidence of insurability (including conditions arising out of acts of domestic violence), Mental or physical disability or medical condition. The policy focuses on professional ED claims . Be sure to include the codes with the most specific definition of the diagnosis, procedure, and/or associated result. Use codes associated with HEDIS/QARR value sets. All Rights Reserved. Coding Edit Rules (new for facility claims and new edits for, Co-Surgeon/Team Surgeon Modifiers 62/66, Definitive Drug Testing (Commercial & Medicaid - limits and exclusions enforcement starts in 2022), E/M Supplemental Reimbursement Policy 2021 Update, HCPCS and CPT Coding Requirements for Outpatient Claims (Commercial), Intraoperative Neurophysiology Monitoring (IONM), National Drug Code (NDC) Requirements for Drug Claims, No Cost/Reduced Cost Drugs, Implants & Devices (, Prolonged Services (Commercial and Medicare), COVID-19 Vaccine and Monoclonal Antibody Infusions Reimbursement Policy, Modifier PO/PN Guidelines for Clinic Services (G0463), Never Events/Adverse Events & Serious Reportable Events (Commercial), Outpatient Imaging Self-Referral Reimbursement Policy. Starting Jan. 1, 2021, ESI will begin utilization management of HIP's Medicare and Medicaid members for most medications. EmblemHealth will acknowledge, in writing, receipt of a grievance that is submitted in writing no later than 15 days after its receipt. We will not disclose their address or telephone number for the duration of the order. MVP uses state-of-the art optical imaging and optical character recognition (OCR) for all paper claims. Reimbursement may be reduced by up to 25% for timely filing claims denials that are overturned upon successful appeal. Quality Assurance Reporting Requirements (QARR) captures the quality of that care. Find our Quality Improvement programs and resources here. This may reduce chart collection. Please post these standards in your office for your appointment schedulers. Theseresults help toshow areas where there is room for improvement. Here are some non-clinical tips to boost your measurement scores: When billing, use the correct codes which relate to ALL services given during the visit. 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