HOW TO READ OUR ID CARDS Generic ID card with each part explained. •Pay attention to logos and instructions on back of ID card. •Referrals and pre-authorizations are not a guarantee of payment.
... preauthorizations, claims, and more, please see the Beacon Health Options Provider Manual: beaconhealthoptions.com/providers/beacon/handbook/. 25 ...
Doing Business with EmblemHealth 2021 OVERVIEW FOR 29-I PROVIDERS The information provided in this presentation is for educational purposes only and does not contain PHI. WELCOME 29-I PROVIDERS During this presentation, we will share information about: · Who we are · Resources for you · How to read our member ID cards · The importance of following access and availability standards · Our managed care partners · Using our secure provider website · Transactions you need to know · Resources to share with members 2 EmblemHealth Legacy, Mission and Values 3 WHO WE ARE · EmblemHealth is one of the nation's largest nonprofit health plans, serving more than 3 million Medical, Dental, and Vision members who live and work across the New York tristate area. · To our members, prospects, and partners, EmblemHealth helps to guide hardworking individuals navigate the medical system, offering straightforward solutions, and making better health more achievable. 4 OUR MISSION Create healthier futures for our customers and communities as an enterprise. 5 Resources for Our Providers 6 EMBLEMHEALTH.COM/PROVIDERS Provider Resources 7 PROVIDER RESOURCES Provider Toolkit 8 PROVIDER RESOURCES Provider Toolkit Tools to Note Send completed Transmittal Forms to Medicaid_Care_Coordination_@emblemhealth.com 9 PROVIDER RESOURCES Join Our Network · Complete Organizational Credentialing application · Provide current and valid 29-I license to operate (if applicable) · Provide valid NPI (National Provider Identifier) · Provide proof of current Professional and General Liability coverage with minimum limits of $1 million per occurrence and $3 million aggregate · Confirmation by primary source that the provider is free of regulatory exclusion, preclusion, or debarment · Confirmation of Medicaid Enrollment (if contracted for Medicaid) · Confirmation of Annual Certification Statement for provider billing Medicaid · Disclosure of Ownership for Medicaid · Accreditation (if mentioned on application) 10 EMBLEMHEALTH.COM/PROVIDERS Clinical Corner 11 EMBLEMHEALTH.COM/PROVIDERS Claims Corner 12 HOW TO READ OUR ID CARDS Generic ID card with each part explained. · Pay attention to logos and instructions on back of ID card. · Referrals and pre-authorizations are not a guarantee of payment. Member must be eligible for coverage on the date of service. Member name CARD FRONT Plan name CARD BACK Member ID number Network name PCP name Copays Customer service phone number Claims address- This address is where all 29-I's will send their Core health related Claims and Medical OLHRS claims. 13 ID CARDS (Continued) The card below shows when a PCP has not been selected, and unless provided will be auto-assigned to member. 14 ID CARDS (Continued) Managing entities (Healthcare Partners, Montefiore or SOMOS) 15 Access to Care 16 FOLLOW ACCESS AND AVAILABILITY STANDARDS · Keep your 29-I address information and contact's current. · Know your network participation. Have you contracted (in-network/par) with EmblemHealth and/or Beacon Health Options for behavioral health services? · If your member requires clinical care after office hours, please contact the Nurse Triage line at 877-444-7988. Foster Care Initial Health Services and Ongoing Assessment and Treatment Time Frame 24 Hours 5 Days 10 Days 30 Days 30 Days 30 Days Activity Mandated Activity Initial screening/screening for X abuse/neglect For children under the age of 13, conduct X HIV risk assessment * Request consent for release of medical X records & treatment Initial medical assessment X Initial dental assessment X Initial mental health assessment X Mandated Who Performs Time Frame X Health practitioner (preferred) or child welfare caseworker X Child welfare caseworker or designated staff X Child welfare caseworker or health staff X Health practitioner X Health practitioner R Mental health practitioner 30 Days 45 Days Family Planning Education and X X Health practitioner Counseling and follow-up health care for youth age 12 and older (or younger as appropriate) Initial developmental assessment X R Health practitioner 45 Days Initial substance abuse assessment R R Health practitioner 60 Days Follow-up health evaluation R R Health practitioner 17 Managing Entities and Special Programs 18 MANAGING ENTITIES AND SPECIAL PROGRAMS EmblemHealth contracts with several delegated entities to provide care to it's members (in addition to other providers). The delegated entity is listed on the member's ID card. When a member is assigned or chooses a PCP associated with one of the delegated entities, the delegated entity will be responsible for coordinating care, as well as, utilization management and case management. Montefiore CMO HealthCare Partners (HCP) SOMOS Reminder: As a 29-I health facility, you will never send CLHRS/OLHRS claims to any of the managing entities listed above 19 MANAGING ENTITIES AND SPECIAL PROGRAMS EmblemHealth also contracts with provider/vendors to provide special programs for members. These provider/vendors are considered network providers. Preauthorization, if required, must be obtained directly from these vendors. · Core Limited Services (VFCA/ Foster Care population only) · Other Limited Health-Related Services (VFCA/Foster Care population only) · Behavioral Health (Beacon) · Vision (EyeMed) · Dental (DentaQuest) · Physical and Occupational Therapy (Palladian) · Pharmacy/Specialty Pharmacy (Express Scripts and Accredo) · Cardiology, DME, Inpatient Rehab, Home Health, LTC, Radiology, Radiation Therapy, SNF (eviCore) · Spine surgery and pain management (OrthoNet) · Laboratory services (Quest Diagnostics) 20 VOLUNTARY FOSTER CARE AGENCY (29-I)/FOSTER CARE POPULATION ONLY Beginning July 1, 2021, EmblemHealth will be responsible for covering the following 29-I Health Facility services for eligible Medicaid members in NY State: 1. Core Limited Health-Related Services (CLHRS) on a per diem basis, inclusive of: Nursing Services, Skill Building Licensed Behavioral Health Practitioner (LBHP), Medicaid Treatment Planning and Discharge Planning, Clinical Consultation/ Supervision Services, VFCA Managed Care Liaison/Administration 2. Medically necessary Other Limited Health-Related Services (OLHRS) on a per encounter basis that the 29-I Health Facility is authorized by the State to provide will include Medicaid State Plan amendments and carved in behavioral health benefits for children, i.e., Children and Family Treatment Supports and Services (CFTSS), Other Licensed Practitioners (OLP), Community Psychiatric Supports and Treatment (CPST), and Home and Community Based Services (HCBS). 21 VFCA (29-I)/FOSTER CARE POPULATION ONLY CLAIMS · All fully contracted and credentialed in-network providers are eligible to bill for CLHRS and OLHRS. · All claims will be sent to EmblemHealth by paper or electronic submission for processing. · 29-I Health Facility Billing Tool at 29ibilling.ctacny.org/ · Out-of-network 29-I health facility providers are eligible to bill through the establishment of Single Case Agreements. · For Essential Community Providers (ECP) EmblemHealth will work with 29-I health facilities to identify any needed services that are better provided by a ECP. If ECP is not in network, EmblemHealth will contract with ECP or establish a single case agreement. For more information about Single Case Agreements, contact the EmblemHealth Foster Care Liaison at Medicaid_Care_Coordination_@emblemhealth.com. 22 VFCA (29-I)/ FOSTER CARE POPULATION ONLY CLAIMS TESTING APPROACH 1. 29-I Health Facility Providers to share the EDI 837 files through email with the Trading Partner update as "TRI". 2. EDI 837 P/I files received from 29-I Health Facility Providers to be loaded into Facets through BizTalk via the below formats. a. File Transfer Process b.TA1, 999, and 277 CA acknowledgments 3. Claims to be adjudicated and priced based on the contracted rates Rate Codes configured against the Agreement Pricing Rule/Fee Schedule. Please see below testing scenarios that will be shared with your health facility. a. Provider and Member Validation b. Clinical Data Validation c. Benefit and Price Calculation d. Pricing Accuracy (Agreement ID, Fee Schedule, Rate Code) 4. QA to share the Pricing Accuracy Summary Report (Response File) to Provider. 23 VFCA (29-I)/ FOSTER CARE POPULATION ONLY CLAIMS TESTING TIMELINE Task Duration in day(s) Receive EDI 837 I/P claims file from 29I Facility Provider through email/MFT 1 Internal testing performed on the EDI Claims file received 5 Raise defects for the issues identified during testing 5 Fixing the defects 5 Retest the fix 2 Notify the Provider for any issues on the Claims file 1 Receive the corrected EDI Claim files from the Providers 3 Retest the EDI Claim files 2 Provider/RM sign-off 2 24 BEHAVIORAL HEALTH SERVICES Beacon Health Options administers behavioral health services and behavioral health OLHRS for foster care children. As a 29-I facility you will contract with Beacon Health Options to provide these services. · Members should contact Beacon Health Options under the Emblem Behavioral Health Services Program (EBHSP). · For preauthorization, call 888-447-2526. · 29-I facilities may also contact the EmblemHealth Foster Care Liaison for further assistance at Medicaid_Care_Coordination_@emblemhealth.com. For information on accreditation, preauthorizations, claims, and more, please see the Beacon Health Options Provider Manual: beaconhealthoptions.com/providers/beacon/handbook/ 25 VISION SERVICES EyeMed is the vision services provider for EmblemHealth members' routine vision and materials benefit. EyeMed is responsible for the provider network, including contracting and credentialing, claims processing and payment, routine vision grievances, and claims appeals. To find an in-network EyeMed provider, contact EyeMed Customer Service at 877-324-2791 (TTY: 711) or you can contact the EmblemHealth Foster Care Liaison at Medicaid_Care_Coordination_@emblemhealth.com. 26 DENTAL SERVICES DentaQuest administers comprehensive dental benefit to members. DentaQuest is responsible for the provider network, including contracting, credentialing, claims, grievances, and appeals. Go to dentaquest.com for more details, or call DentaQuest at 844-822-8108, Monday to Friday from 8 a.m. to 5 p.m. You may also contact the EmblemHealth Foster Care Liaison for assistance at Medicaid_Care_Coordination_@emblemhealth.com. 27 PHYSICAL AND OCCUPATIONAL THERAPY (PT/OT) PROGRAM Palladian Health manages PT OT services. · Providers can contact Palladian directly or work with the EmblemHealth Foster Care Liaison Medicaid_Care_Coordination_@emblemhealth.com · Outpatient PT/OT requires preauthorization after initial visit. · Contact Palladian for the member's second/seventh treatment, as applicable, and each treatment thereafter. · Submit completed medical necessity review forms found on evicore.com/palladian By Mail: Palladian PO Box 366 Lancaster, NY 14086 · Exclusions: For HCP and Montefiore CMO, PT/OT services are preauthorized by these managing entities (update on grid as well) PT/OT services rendered by a podiatrist are preauthorized via the podiatrist 28 PHARMACY SERVICES AND SPECIALTY PHARMACY PROGRAM Express Scripts (ESI) performs drug utilization management services for EmblemHealth members. Pharmacy Drug Reviews Phone: 888-281-5539 Fax: 877-251-5896 Medical Drug Reviews Phone: 877-681-9866 Fax: 866-896-1209 EmblemHealth works with Accredo, an Express Scripts subsidiary, to administer complex specialty pharmacy medications through our Specialty Pharmacy Program. Phone: 855-216-2166 Fax: 888-302-1028 Online: accredo.com 29 EVICORE SERVICES eviCore healthcare conducts utilization management for: Service What Do Doctors Who Make Community Referrals Need to Know? Cardiology DME* Inpatient Rehab* Home Health Care* Long-Term Care* Radiology Radiation Therapy Skilled Nursing Facility* Contact eviCore to request approval for cardiology imaging services in most outpatient settings. Phone: 866-417-2345; Fax: 800-540-2406 Contact DME company; they submit approval requests. Phone: 866-417-2345; Fax: 855-488-6275 Contact facility; they submit approval requests. Phone: 866-417-2345; Fax: 855-488-6275 Contact agency; they submit approval requests. Phone: 866-417-2345; Fax: 855-488-6275 Contact facility; they submit approval requests. Phone: 866-417-2345; Fax: 855-488-6275 Contact eviCore to request approval for diagnostic imaging for outpatient radiology services. Phone: 866-417-2345; Fax: 800-540-2406 Contact eviCore to request approval for radiation therapy treatment plans rather than for individual CPT-4 codes. Phone: 866-417-2345; Fax: 800-540-2406 Contact facility; they submit approval requests. Phone: 866-417-2345; Fax: 855-488-6275 *To identify the provider of your choice please go to emblemhealth.com/find-a-doctor lookup tool 30 EVICORE SERVICES (Continued) Before requesting preauthorization, complete applicable request form found on evicore.com eviCore conducts first-level clinical standard and expedited appeals Note: Preauthorization is not required for services provided as part of an inpatient hospital stay or an emergency room encounter. eviCore works with inpatient facilities on discharge planning and the foster care liaison, and moving the member to the next level of care. 29-I facilities may work directly with the EmblemHealth Foster Care Liaison at Medicaid_Care_Coordination_@emblemhealth. com. For More Information eviCore provides a variety of training modules on their website: evicore.com. 31 EMBLEMHEALTH SPINE SURGERY AND PAIN MANAGEMENT THERAPIES PROGRAM Contact OrthoNet, LLC for preauthorization for: · Select spine surgery for codes requiring preauthorization and related forms, see the EmblemHealth Spine Surgery and Pain Management Therapies Program chapter 12 of the Provider Manual at emblemhealth.com/providers. · Interventional pain management therapy procedures Service Sites: · Office (POS 11) · Outpatient hospital (POS 22) · Ambulatory surgery center (POS 24) · Inpatient hospital (POS 21) 32 NETWORK LABORATORY SERVICES · Use in-network labs found on: emblemhealth.com/provider/resources/too lkit/network-laboratory-services-for-allplan-members · Quest is our preferred free-standing lab. Quest Diagnostics Patient Services Locator: 800-377-7220 Quest Diagnostics Customer Service department: 866-MY-QUEST (866-697-8378) Quest Diagnostics website: questdiagnostics.com · Use other contracted labs only for proprietary test and services Quest cannot perform. · Physicians may also use network hospitals. In limited circumstances, in-office lab tests may be performed. 33 Secure Website Registration and Security Application 34 EMBLEMHEALTH.COM/PROVIDERS 35 REGISTER FOR ACCESS On this page, scroll down to Register. 36 REGISTER FOR ACCESS (Continued) Enter and validate your Tax 1 ID number. 2 Enter user's name and email address. 3 Enter provider's PRIS number. 1 3 2 37 REGISTER FOR ACCESS (Continued) 1 1 Answer all fields with (*). 2 We recommend sending password via email for instant access to our online services. 3 Select relationship to provider. 4 Enhanced security. 4 2 3 38 SECURE PROVIDER WEBSITE HOME PAGE Provides a secure environment to view member and provider information such as: · Claims/Checks · Benefits/Eligibility · Referrals · Pre-Certification · Preauthorizations · EFT/ERA · Lab Ordering · Results · Benefit Extension · Provider Profile · Message Center · Provider Credentialing Tool · Security Application · Panel Report (PCPs only) · Change Email 39 SECURITY ADMINISTRATION Registration 1 Select Manage Users Allows a physician or administrator to add new users or delete existing users. Note: This function may not be available at this time for all lines of business (LOBs). 1 40 SECURITY ADMINISTRATION Registration (Continued) · User may select a personal ID and password. · Password must be 5 20 characters and consist of letters and numbers only. Note: This function may not be available at this time for all LOBs. Enter User Information Marked with an (*) 41 SECURITY ADMINISTRATION Registration (Continued) 42 SECURITY ADMINISTRATION Assign Roles · The administrator can change the employee's role(s) at any time. · Roles should be based on the employee's job function. Note: This function may not be available at this time for all lines of business. 43 COMMUNICATING WITH US Message Center · Secure environment, PHI protected · Access available 24 hours a day, 7 days a week · Quick response time · Reduces need to call EmblemHealth directly · Saves provider time and money If you do not receive timely notification, please contact the EmblemHealth Foster Care Liaison directly at Medicaid_Care_Coordination_@ emblemhealth.com 44 KEEP YOUR DIRECTORY INFORMATION CURRENT Verifying Provider Information · Periodically, providers are asked to review and update their provider and practice information. · Select link to review and update your practice and provider information quickly and easily. · The Provider Profile allows you to update your W-9. · Incorrect information leads to payment errors and incorrect listings in our directories. 45 PROVIDER PROFILE Updates & Networks 1 Provides a snapshot of the information on file with EmblemHealth. · To correct or change a provider's information, select the "Update" link and make your changes. · If you cannot complete an update online, submit changes via: Email: providermodifications@emblemhealth.com Fax: 877-889-9061 · If you are affiliated with an EmblemHealth-delegated entity, please submit any profile changes to that entity. 2 To locate the networks in which you are contracted, select the "Update" link for your Physician Locations. Note: This feature is not available to hospital physicians and should not be used by physicians under a delegated credentialing relationship. 1 12 46 PROVIDER PROFILE Find Your Networks John Doe, MD Edit your location information here Provider Network Participation Benefit Plan Participation This page is displayed when you select the "Update" link from the Provider Profile page. You may edit or update your location information or find your network affiliations and participating products (plans). 47 PROVIDER PROFILE Update Your Office Hours 1 New York State Department of Health requires us to have your practice's accurate office hours on file. Please sign in to emblemhealth.com/providers to update your office hours or other information by following the instructions below: 2 Select "update" for each Physician Location found on the lower portion of the Provider Profile screen. Scroll down past Network Affiliations and Participating Products to the first location address. Complete all updates. 3 Select "Save All Changes" to save your updates. 1 2 3 48 Transactions 49 ELIGIBILITY 1 Eligibility screen shows if the patient is active and whether the plan is primary. 2 Clicking on a link or underlined field takes you to additional information about that member. 3 Plan type indicates member's plan coverage. 2 1 3 50 ELIGIBILITY AND BENEFITS SEARCH · User may search a patient's benefits and/or eligibility either by: ID number Member's last name and date of birth · When searching by ID number, several members and lines of business can be requested at one time. · Note: You must add a comma between each ID number. 51 BENEFIT DETAILS SUMMARY 52 CLAIMS Search 1 You must select a plan type and category. 2 Search for a claim by date range, patient ID, claim number, check number, or status. 1 · If signed in under a TIN number, you will see all claims at all locations. If signed in under a PRIS number, claims will be specific to provider and location. 3 View up to 1,000 lines on screen or download up to 3,000 lines. · Claims information available for 18 months. · Spreadsheet can be sorted to meet your office needs. · Less is best -- no need to enter data in all fields. 1 2 3 53 CLAIMS Download Search 54 CLAIMS Search Results · Claims listed by doctor and by plan. · Click on the underlined fields to obtain additional detailed information when you sign into your account 55 CLAIMS Search Results Details Click on "check number" for check detail information in your account 1· Payment summary indicates member's responsibility. 2· Note(s) column indicates reason for denial. 3· Contact EmblemHealth to submit a claim inquiry. 4· Claim Detail screen is equivalent to the Explanation of Payment notice. 2 3 4 2 1 56 TAXONOMY CODES WHAT ARE THEY? Provide taxonomy codes on all EmblemHealth claims; absence of these codes may result in incorrect payment. Taxonomy Codes What Are They? · Unique 10-character alphanumeric code · Used to identify individual or organization provider type and specialty at the claim level · Codes have three distinct levels: · Level I is the Practitioner Type · Level II is Classification · Level III is the Area of Specialization A complete list of taxonomy codes can be found within the Health Insurance Portability and Accountability Act (HIPAA). 57 57 TAXONOMY CODES HOW DO I USE THEM? How to Submit Taxonomy Codes on Your Claims The Foster Care Agency taxonomy code for all 29-I Health Facilities is 253J00000X and must be on all claims UB04 HCFA 1500 Billing Provider Taxonomy: Box 81a with B3 qualifier Billing Provider Taxonomy: Box 33B Qualifier ZZ Attending Provider Taxonomy: Box 81b with B3 qualifier Rendering Provider Taxonomy Line Level : 24J Qualifier ZZ Transaction Type Taxonomy Code Billing Taxonomy 837P Rendering Taxonomy Claim Level Rendering Taxonomy Line Level Billing Taxonomy 837I Attending Taxonomy Claim Level Loop 2000A 2310B 2420A 2000A 2310A Segment Data Element Data Element PRV PRV01 = BI PRV02 = PXC PRV PRV01 = PE PRV02 = PXC PRV PRV01 = PE PRV02 = PXC PRV PRV01 = BI PRV02 = PXC PRV PRV01 = AT PRV02 = PXC Data Element PRV03 Taxonomy Code PRV03 Taxonomy Code PRV03 Taxonomy Code PRV03 Taxonomy Code PRV03 Taxonomy Code 58 EFT/ERA To register: After you receive your first CPR payment via ECHO Health VCard, you have the option to enroll in EFT/ERA by contacting ECHO Provider Support at 888-492-0032 or enrolling online at: enrollments.echohealthinc.com/ · If a provider enrolls for EFT through this link: enrollments.echohealthinc.com/EFTERADirect/EmblemHealth, there is no charge for EFT/ERA service. · Alternately, ECHO offers an "All Payer" service for a fee (per draft) which is a contracted percentage with the provider. The benefit to the provider is that once enrolled, their EFT choice applies regardless of the payer as long as it is processed by ECHO. The provider signs a contract agreeing to this before the first draft. EmblemHealth recommends the use of EFT/ERA because it can: · Improve your cash flow. · Reduce administrative expenses. · Match payments to remittances quickly and easily. · Manage the destination of your claims payments. · Manage user access 59 CLAIMS Filing a Claims Dispute Web Inquiry · Sign in to emblemhealth.com/providers. · Click on "Claims/Checks" link. · Click on the applicable claim. · Note in the Comment section the nature of the inquiry. · Reply back if you need further clarification or want to supply additional information. · If you have a claim or multiple claims to dispute, use our Message Center to attach a file, such as a corrected claim, a primary Explanation of Benefits notice, or medical records, etc. Grievance · A request to change an adverse determination that was based on administrative policies, procedures, or guidelines. · A grievance may result from how a claim was processed, including computational errors, interpretation of contract reimbursement terms, timeliness of payment, or from failure to follow a plan policy or procedure. · Refer to EmblemHealth's Provider Manual for more information on our grievance policy and procedures. Note: as of April 1, 2019 EmblemHealth applies a default 120-day timely filing requirement for par providers. Unless the participation agreement states an alternative time frame to be applied, all claims need to be submitted within 120 days of the date of service. This timely filing limit applies to original and corrected claims submitted by participating providers. 60 PREAUTHORIZATION Inpatient hospital admissions, hospice, assistant surgeon, non-par providers, ambulance, and outpatient services may require preauthorization. For a list of services requiring preauthorization, see Clinical Corner at emblemhealth.com/providers. A new Preauthorization Look-up Tool has been added to Clinical Corner in addition to the one available in the secure provider portal as part of the Prior Approval transaction. · When possible, all requests for preauthorization should be coordinated with the EmblemHealth Foster Care Liaison. · Preauthorization is not required for Core Limited Health-Related Services. · Preauthorization may be required for Other Limited Health-Related Services. · Preauthorization requests can be submitted via: · EmblemHealth Foster Care Liaison: Medicaid_Care_Coordination_@emblemhealth.com · Online: emblemhealth.com/providers · Phone: 866-447-9717 · Fax: 866-215-2928 If a PCP is associated with SOMOS, CMO, or HCP, they will contact the number identified on the member's ID card. They may also reach out to the EmblemHealth Foster Care Liaison for assistance. Emergency hospital admissions do not require preauthorization; however, the hospital must notify the plan within two (2) business days. 61 PREAUTHORIZATION RULES 62 PREAUTHORIZATION TRANSACTION Select transaction 63 PREAUTHORIZATION TRANSACTION (Continued) Provide details 64 PREAUTHORIZATION TRANSACTION (Continued) Opportunity to review and edit. 65 PREAUTHORIZATION TRANSACTION (Continued) Opportunity to provide clinical information offered. 66 PREAUTHORIZATION TRANSACTION (Continued) Answer clinical questions. 67 PREAUTHORIZATION TRANSACTION (Continued) Confirmation of submission. 68 REFERRALS All referrals must be done via the website. · Select Referrals link in the left column. · PCPs can request referrals for specialist care. · Users can also view referrals entered by the PCP. · Give referral to member before they leave the office. 69 REFERRALS (Continued) Providers can request a new referral by either entering the member's "ID number" or the "Last Name" and "Date of Birth". 70 REFERRALS (Continued) · System returns member Doe, Jane. · User has the option of selecting this member or conducting a New Search. 71 REFERRALS (Continued) 1 Referral Request returns with these fields populated: · Member ID · Name · Birth Date 2 1 · Plan Data 2 Select Service Date via calendar. 3 System returns dropdown menus: 3 · Facility Code · (POS) Place of Service · Release of Information Office (11) should be selected if the service requested by the PCP is a Consultation. Note: A pop-up window will appear if the member is enrolled in EmblemHealth Enhanced Care Plus (HARP). 72 REFERRALS (Continued) Referral Request Enter: 1 Service type/level 2 Servicing Provider PRIS or NPI, or use Search to find provider 3 Diagnosis code 4 Select procedure 5 Enter number of visits (6 maximum) 6 Enter free-text comments. 1 3 4 6 2 5 73 REFERRALS (Continued) Details Review Page This is the final chance to edit/make changes before submitting the Referral Request. When complete: Select Submit 74 REFERRALS (Continued) If all criteria are satisfied, system returns: 1 My Trace Number 2 Authorization Number 3 Review Status My Trace Number or Authorization Number can be used to search for referrals. 1 2 3 75 REFERRALS (Continued) Providers may search for member referred by them or referred to them. 76 Resources for Our Members 77 EMBLEMHEALTH NEIGHBORHOOD CARE EmblemHealth Neighborhood Care offers our plan members and other community members a place to get the personalized, one-on-one support of experts in clinical, benefits, and health management solutions in support of a holistic approach to health and wellness. Neighborhood Care does not provide medical services; our role is to help practitioners manage patient care by supporting the primary practitioner-patient relationship. Using the EmblemHealth Neighborhood Care visit form, providers can recommend plan members to a local Neighborhood Care site for services including: · In-person EmblemHealth Customer Service* ID cards, claims and billing questions, provider search · Care management and coordination for EmblemHealth members* Referrals, pharmacy questions, durable medical equipment, fulfillment assistance · Social work and community navigation Housing, employment and financial assistance, behavioral health resources · Fitness and wellness classes Zumba, yoga, nutrition, disease prevention, self-management programs For more information, visit emblemhealth.com/community. *This denotes that 29-I facilities, VFCA, or LDSS can only receive this information through EmblemHealth Customer Service and/or the EmblemHealth Foster Care Liaison. 78 MYEMBLEMHEALTH APP The myEmblemHealth app allows our members to get key plan information, services, and features any time they want, wherever they are. Find a plan doctor, dentist, or hospital · Help them locate providers when generating a referral. · Get a map and directions using the device's GPS (location services must be turned on). Did they forget their ID card at home? No problem. · Display member's ID card and even email or fax it to your office. · Display member's plan benefits and copays. · Display member's designated PCP, if selected. Security EmblemHealth members must first sign in or register to access this app. Member information is always safe. Compatible with iOS and Android devices. 79 CARE4TODAY APP 80 ADDITIONAL INFORMATION TO ASSIST A 29-I HEALTH FACILITY · Throughout the presentation we have mentioned the ability to connect directly with the EmblemHealth Foster Care Liaison (FCL). The FCL will conduct one on one meetings after your provider training to share additional information and familiarize you with our clinical processes. · At the time of the meeting, the FCL will share her direct contact information. However, we recommend for immediate assistance that the 29-I facilities work directly with the EmblemHealth Foster Care Liaison through this mailbox: Medicaid_Care_Coordination_@embl emhealth.com 81 Our partnership is important to us and we look forward to continuing the work we're doing. 82 Thank you for caring for our members. 83
Provider | EmblemHealth
29ibilling.ctacny.org/
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ECHO HealthECHO Health
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Dental Insurance Benefit Solutions | Dental Insurance Benefits Administration - DentaQuestNeighborhood Care | EmblemHealthProvider | EmblemHealthNetwork Laboratory Services for All Plan Members | EmblemHealth
eviCore Healthcare | Empowering the Improvement of CarePalladian | eviCore
Home | Quest Diagnostics