Emblem Health:  claims timely filling update- Self Funded Plans (ASO)

Keeping up current on any claim timely filing updates is crucial for your business!

Claims that are denied for timely filing can be rarely appealed and get paid. (Certain situations like COB/Natural disaster)

So, I always pay a close attention to any timely filling changes that are reported by the healthcare payers/plans.

Below please note the changes that took place for Self Funded (ASO) type of plans.

Find this type of information useful? Please follow my blog for more healthcare related information.

• UHC to remove prior auth for some radiology and cardiology tests.
  Starting Jan 1, 2026 certain nuclear imaging tests, OBGYN ultrasounds, and certain cardiology tests will no longer require a prior authorization for some of the  following plan types: 1.UnitedHealthcare Insurance Company2.UnitedHealthcare Mid-Atlantic, inc. 3.UnitedHealthcare Plan of the River Valley, Inc. and 4.UnitedHealthcare Insurance Company of the River Valley5.Oxford Health Insurance, Inc.United Healthcare Level Funded (formerly All… Read more: UHC to remove prior auth for some radiology and cardiology tests.
• Anthem BCBS NY: New PET tracer UM policy
  The following information will apply to any DOS on 12/1/25 and thereafter. Starting 12/1/25 the PET tracer will require an auth in addition to PET services. Please submit both PET and radiotracer codes- for prior authorization. The UM criteria for PET will not be affected. However both codes will be either approved or denied. Please… Read more: Anthem BCBS NY: New PET tracer UM policy
• PrEP proper billing and coding
  Proper Medical coding and billing is important to the financial health of your practice! Medication codes: Administration code Please avoid using the regular 96372 administration code. Instead use the following administration code: G0012 This code is used when the provider physically administers the PrEP medication. Supply Code For the oral PrEP pharmacies should bill: Q0251… Read more: PrEP proper billing and coding
• MVP to end its relationship with naviHealth, Inc
  Currently naviHealth, Inc handles Utilization and Case/Care Management for post-acute services—including Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), and Home Health—for MVP Medicare Advantage, DualAccess, and DualAccess Complete Members. However, MVP and naviHealth, Inc will end their contract as of Dec 31st 2025. Starting on Jan 1,2025 MVP will process these requests in house.… Read more: MVP to end its relationship with naviHealth, Inc
• MVP postpartum program incentive payments: NY providers!
  Are you any of these following providers in NY? OB/GYN Family Medicine Certified Nurse Mid-wives Nurse Practitioner – Family Health Then this blog post is for you! NY DOH established an additional payment (to global OBGYN bundled payment) for providers that complete a person-centered postpartum visit— including a depression screening—within 12 weeks of delivery, as… Read more: MVP postpartum program incentive payments: NY providers!