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 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. Below is a summary of the substantive updates posted since December 2021 including a new policy that will go into effect in 2023: Note: As of May 1, 2022, Commercial and Medicare claims submitted with missing, invalid, or incomplete NDC or other information are being denied. Filing The Claim With EmblemHealth Provider. Hard-copy forms can be requested by calling the U.S. Government Publishing Office at 800-869-6590 or 202-512-1800. They will be able to view information, but not submit new transactions. If you missed any, youll find links to the messages in the Your Resources section below. Nov. 8 and Nov. 17, 2022. Until the COVID-19 State of Emergency ends, our Medicare members with plans that traditionally require referrals may continue to see specialists without referrals. If you have any concerns about your health, please contact your health care provider's office. It defines our 2023 offerings. Instead of calling for claims status, you can quickly find the information on our provider portal. If you need to file a claim personally, contact the member services department at 1-877-842-3625. To refer a patient to the EmblemHealthHIV Case Management program, please call or have the member call800-447-0768. They expect to be treated with dignity, in aculturally competent manner, free from discrimination, and to havetheir rightshonored. Even better, you have access to Downloadable Claim Reports. Outside NYC: 1-800-624-2414. By using the portal instead of faxes, you help us get started on your reviews sooner since the requests are legible. Pulse8 offers free webinars for patient management and ICD-10 coding. This includeshome health care, skilled nursing facilities, acute rehabilitation, andlong-term acute care hospital admissions. Find our Quality Improvement programs and resources here. The main call center switchboard will then route your call to the appropriate area. ConnectiCares Medical Policies are posted on the Medical Coverage Criteria page. 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. For information on prior approval, claims submission, and claims status please visit Beacon Health Options. Instead of calling for claims' status, you can quickly find the information on our provider portal. A member's experience often begins with their use of our provider directories. Routine maintenance will be covered in the following outpatient settings: We will allow exceptions for initial doses and members with justifiable needs to continue care in a hospital outpatient setting. EmblemHealth 55 Water Street New York, NY 10041-8190 Provider Services is available 8 a.m. to 6 p.m., Monday to Friday. For changes to ConnectiCares benefit plans and delivery system that could affect EmblemHealth providers treating ConnectiCare members, see ConnectiCares News and Updates and our Office Visit Newsletter. Emblem VFCA Information. Upload Your Documents Dont Fax Them: We encourage you to take advantage of the provider portal to uploaddocumentsin support of your preauthorization requests, concurrent reviews, and discharge plans. 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. Those who follow established guidelines and best practices are successfully increasing quality measure scores and patient satisfaction. Neighborhood Care does not provide medical services. EmblemHealth Contact Information Customer Service is available seven days a week (excluding major holidays), 8 am to 8 pm. Access to the NYCBS coordinator who will obtain any required preauthorizations from EmblemHealth, significantly decreasing the administrative burden on your staff. The Provider Toolkit has guides and quick references to help with the administration of our plans. 2020 EmblemHealth. If you are seeking employment at CenterLight, please call our Human Resources job hotline . Whether youre a first-time user who needs to set up an account, or a regular user who wants to learn how to do more, we have videos, step-by-step guides, and Frequently Asked Questions (FAQs) to get you moving: We appreciate your commitment to caring for our members. EmblemHealth Fact Sheet. There could be a brief delay between the time when providers file claims with EmblemHealth and when claims appear in your account. You may use telehealth/virtual care to close gaps in care. SeeourProvider Manualand new Quality Improvement page to learn more about our Quality Improvement Program. To ensure public safety and track conditions affecting public health, the federal government, New York State, and New York City agencies have enacted laws that must be followed by health care professionals. Here is a summary of the key updates posted this last year and those anticipated for 2023. You can save time by checking Provider Help and Support page's compilation of frequently asked questions and answers before contacting Customer Service. Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. 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. SOMOS Innovation Program FAQs. New York Cancer & Blood Specialists (NYCBS) A Concierge Experience. See the Clinical Corner section below for other provider portal improvements. 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. Even better, you have access to Downloadable Claim Reports. Members and non-members alike can visit Neighborhood Care and take advantage of our classes, tools, and face-to-face support. The following includes information to help you meet members' expectations and outlines the ways that we are measured in meeting them. Upload documentation while creating a preauthorization request or afterwards by going back into the same preauthorization request to supplement the request and to provide concurrent review information. Visit our EmblemHealth Preauthorization Lists page to see what requires preauthorization and who is responsible for the utilization review. Our team will work with the member to make sure they are educated about their condition, have needed resources, and get the right care to feel better. That's why we created Claims Corner a resource where you will find updated information on claims policy, best practices for coding your claims, changes to regulatory-driven payment methodology and other useful claims-related tips. Any information provided on this Website is for informational purposes only. Timely Submission Participating Providers: Tell Us What You Think! The Clinical Corner section of the EmblemHealth provider website is part of the EmblemHealth Provider Manual and houses Administrative Guidelines described in our participation agreements. To see announcements of formulary changes, see EmblemHealths 2023 Formulary Updates webpage. TheLearning Onlinesection of our provider website is filled with required and recommended learning opportunities. We also expect our members to respect you and to honor their responsibilities. It is not medical advice and should not be substituted for regular consultation with your health care provider. emblemhealth.com. Provider Provider Resources Providers Managing Your EmblemHealth Patients The Real Time Transactions and Responses applications (Eligibility 270-271 and Claim Status 276-277) will be unavailable on the following days. If you have any concerns about your health, please contact your health care provider's office. Through ECHO,you can, at no cost, receive direct deposits to your bank account(s) (known as electronic funds transfer (EFT)) and view or download your remittances online (known as electronic remittance advantage (ERA)). All Rights Reserved. The online Provider Manual is an extension of your EmblemHealth or ConnectiCare contract. Additional support:We offer aTransitions of Care programto help members with complex care issues better manage their health after a hospital admission. Take the survey on the Home Page and let us know what you think! If a claim must be submitted on paper, please see Claim Tips for Paper Submissions. Providers without an account can register quickly by clicking here. Schedule time to periodically audit your portal users. If you are a participant of one of our plans and need assistance, please call us our Participant Services Department 1-833-252-2737, Monday-Friday from 8:00 a.m. through 8:00 p.m. TTY users should call 711.. For our network of providers, our Provider Relations department can be reached at 1-800-761-5602.. Be sure we have your email address so you can get these and other important updates. By Phone: You can contact the sales department for EmblemHealth at 1-877-411-3625 and the customer service department for members at 1-877-842-3625. Please join the session thats best suited for your facility/provider type no registration required. Before the end of 2022, EmblemHealth will begin to manage post-acute care (PAC) for EmblemHealth members, replacingeviCore. TheDo I need a referral? - A Quick Guidehas updated resources for 2023, including a video, to help providers understand when a referral is needed. The health and wellness classes support the different dimensions of wellness, including physical, financial, social, and emotional. Information on changes to plan benefits that may have an impact on your claims. Our thanks to you, our partners, for the care you give our members. The links go to permanent webpages where you can view product-specific information all year long: At EmblemHealth, we value our members' experience with us and with you, our contracted providers. Mail paper claims to: EmblemHealth Behavioral Health Claim Services P.O. To find a provider for your EmblemHealth members, useour Find a Doctor tool. NYCBS has agree to provide EmblemHealth members with a concierge experience that includes: For EmblemHealth-contracted providers and their office staff, NYCBS can offer: Email Address:EmblemTreatments@nycancer.com. Direct communication with NYCBS physicians to get up-to-date information on their patients treatment. Once members have found the right provider, their next experience is appointment scheduling. We can help you be more efficient with your administrative processes to save you time. It is not medical advice and should not be substituted for regular consultation with your health care provider. Dispositions apply to all lines of business unless otherwise indicated. 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. Try creating a customized claims report to avoid multiple searches, If youre ready to get going, heres what you need. If you need general assistance, you can call800-447-0768Monday through Friday from 9 a.m. to 5 p.m. ConnectiCare: Call800-390-3522Monday, Thursday, and Friday from 8 a.m. to 4 p.m. or Tuesday and Wednesday from 8 a.m. to 7:30 p.m. Four Clinical Practice Guidelines were updated in 2022: We encourage our providers to consult EmblemHealths Clinical Practice Guidelines (CPGs) for assistance in the treatment of acute, chronic (e.g., HIV), and behavioral health issues. Our vendor partners who manage our Utilization Management Programs will continue to use their own websites and provider portals for transactions. Together, EmblemHealth and Pulse8 promote risk adjustment education and gap closure efforts for our New York State of Health (NYSOH) Marketplace, Medicare HMO, and Medicaid members. Please review so you know whether a member needs a referral to see a specialist. Primary care providers (PCPs) are encouraged to take advantage of these additional compensation opportunities and Pulse8s free monthly webinars. Find the specific content you are looking for from our extensive Provider Manual. 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. Many EmblemHealth and ConnectiCare members have plans which give them access to providers in both organizations. Legal | Nondiscrimination Policy | Digital Services Privacy Policy and Terms of Use | Accessibility Statement | Privacy Policy 2022 EmblemHealth . The provider portal makes coordination of care easier. We also added Care Plans for most members who participate in our Care/Case Management programs. Any information provided on this Website is for informational purposes only. Instead, our role is to help practitioners manage patient care by supporting the practitioner-patient relationship. All Rights Reserved. 1-212-501-4444. 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. Paper Claim Submission Address Contact for Inquiries; HIP / EmblemHealth Insurance Company (formerly HIPIC) Bridge Enhanced Care Prime Prime VIP Prime Bold Reserve: Professional claims: HIP/ EmblemHealth Insurance Company: 55247 HIP plans branded GHI HMO: 25531 HIP plans branded Vytra HMO: 22264: Vendor or direct submission: EmblemHealth PO Box . Provider Information Provider Manual. VisitECHO, click the Click Here button, and follow the instructions to enroll. See if a provider you conduct business for is in-network for a given member. 2910 Exterior Street, First Floor . It is not medical advice and should not be substituted for regular consultation with your health care provider. Benefits Use the Provider Portal for Preauthorization, Concurrent Review, Referral, and ER Admission/Notification Transactions. Spend less time on the phone and feeding documents into a fax machine. 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. 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