Posted in Insurance, Updates

Medicare Advantage Plans (Montefiore CMO) changes, starting 01/01/2020-NY providers/members, EmblemHealth

If you are participating provider in Motefiore IPA, then recently your office received a notice, regarding Montefore CMO Medicare Advantage Plan members.

Below are the outlined changes that will affect the members and your office, starting 01/01/2020


  1. Medicare VIP Prime Network
  2. EmblemHealth will not change the PCP assignments (for the members)
  3. Montefiore IPA contract between the provider and Montefiore will remain in effect.
  4. CMO will provide Management Services for all other EmblemHealth members except Medicare


  1. Referrals- if the referring provider (PCP) is not part of Montefiore IPA, referral is required. PCP’s are encouraged to order the referral, while the patient is still in the office. (The referrals between Montefiore Providers will follow the same workflow as they do today-NO REF is REQ unless is for a specific procedure that does).


  1. Pre-authorizations- EmblemHealth will honor the prior authorizations that were issued by CMO. However, if the patient was seen after the date 01/01/2020 and needs a prior authorization, the provider needs to request it through EmblemHealth website, for non-delegated services. EmblemHealth will be releasing a new prior-authorization list on effective 01/01/2020. This list is available on website. Beacon Health Options is responsible for behavioral health services. Beacon Health Options phone number is 1-888-447-2526.


  1. Submission of Claims- For dates of service that were done on 01/01/2020 and after the providers need to submit the claims directly to EmblemHealth. Providers please sent the claims to CMO, for the dates of service up to and including 12/31/2019. If the patient is admitted to an inpatient facility and is still in the same place of service in 2020, the claims should be submitted to CMO. Discharge planning, will be managed by EmblemHealth in coordination with eviCore if skilled nursing, inpatient rehab, home health care, or durable equipment is needed.

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My name is Kate Patskovska, CPB. I am an Independent Medical Biller CPB (AAPC) and an owner of KR2 Medical Billing. KR2 Medical Billing is a full service Consulting/Medical Billing Business that is dedicated to educating, consulting, and overall improving the "financial health" of your medical practice.

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