Category: EmblemHealth NY

Find Medical Billing and Coding Guidance for EmblemHealth Insurance.

Posted in EmblemHealth NY, NY Providers, Payer Updates

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

Posted on by KR2Medical Billing

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.

Via Emblem Health

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

  • UHC Medicaid: Idaho: diabetic DME coverage change-benefit
    Starting for DOS 4/1/26 and thereafter the following codes will be covered through the patient pharmacy benefit and no longer will be covered under patient medical benefit. For DOS 1/1/26 through 3/1/26- providers can still bill either through medical benefit or pharmacy benefit. Find this type of content useful? Follow my blog!
  • Anthem BCBS: 32BJ fund new TPA and cards
    As the new year starts so do the change of theember ID changes and or group numbers. Is your provider office aware of these changes? Please note that for any 32BJ members there is a new TPA, group#, member ID, and cards. Please note the new ID: Effective Jan 1,2026- new members ID prefix BJVBJ.… Read more: Anthem BCBS: 32BJ fund new TPA and cards
  • Are you leaving revenue on the table?
    Aetna update! Is your practice compliant? Are you appending proper modifiers to radiology, diagnostic services and surgery services- when billed with the following ICD-10 codes: Z53.01, Z53.09, Z53.1, Z53.20, Z53.21, Z53.29, Z53.8, Z53.9? As per Aetna- if the following modifiers are not billed on the claims for the above services with above named ICD-10 codes-… Read more: Are you leaving revenue on the table?
  • Current facia plane block codes
    Is your office compliant- uses the proper codes for facia plane blocks? Back in 2025 CMS released new and updated facia plane block codes to better represent the work that the anesthesiologists perform to reduce the pain for the patients during procedures (thorasic/lower extremity). Imaging is included in these codes. Please note if the EP… Read more: Current facia plane block codes
  • Aetna: reimbursement update ventral hernia
    This change will apply to the dates of service on 4/1/26 and thereafter. The plans that ate affected are commercial and Medicare. Bundled payments: The following codes will no longer be reimbursed separately-15374 and 49649, when billed with the following codes: venrtal hernia Less than 3 cm- 49591 to 49594 and 49613 to 49616 3cm … Read more: Aetna: reimbursement update ventral hernia
Posted in #reimbursement, BCBS (Various States), BCBS Empire NY, Cinga Insurance, EmblemHealth NY, HEDIS Measures, NY Providers, Training

HEDIS Measure: Immunizations for Adolescent

Posted on by KR2Medical Billing

This measure represents the percentage of children who turned 13 years old and received the following immunizations before their 13th birthday.

  • One dose of meningococcal vaccine
  • One tetanus, diphtheria toxoids and one acellular pertussis vaccine (Tdap): and
  • Completed the human papillomavirus (HPV) series.*

*HPV requires 2 shots, at least 146 days apart.

Meningococcal recombinant (serogroup B) (MenB) vaccines- DO NOT COUNT towards the HEDIS measure.

For Meningococcal Serogroups A, C, W, Y:

  • At least one meningococcal serogroups A, C, W, Y vaccine, with a date of service on or between the member’s eleventh and 13th birthdays
  • Anaphylaxis due to the meningococcal vaccine any time on or before the member’s 13th birthday meets criteria

For Tdap: generic documentation (Tdap/Td) can be counted towards this HEDIS measure.

  • At least one tetanus, diphtheria toxoids and acellular pertussis (Tdap) vaccine, with a date of service on or between the member’s tenth and 13th birthdays.
  • If patient has anaphylaxis due to Tdap vaccine during or before pt turns 13 years old
  • Encephalitis due to the tetanus, diphtheria, or pertussis vaccine

For HPV:

  • At least two HPV vaccines on or between the member’s ninth and 13th birthdays and with dates of service at least 146 days apart
  • At least 3 HPV vaccines – w/ different DOS before or on the date when patient turns 13 years of age
  • Anaphylaxis due to the HPV vaccine any time on or before the member’s 13th birthday meets criteria

Accepted documentation:

  • A note with the specific antigen/vaccine and the date of administration of the vaccine
  • A certificate of immunization prepared by an authorized health care provider or agency with information of each vaccine and their administration dates

Not accepted documentation:

A note that says the member is up to date and does not have the actual vaccines listed w/ administration dates

Via Anthem (NY) provider news.

PROVIDERS-some things you can do in your practice in order to meet this measure:

  • Have standing orders for adolescent vaccines- the visit can be performed by a Nurse
  • Use appointment reminders to schedule vaccine appointments
  • For HPV  vaccines make sure to schedule a f/u appt for the next dosage.
  • Educate parents on the importance of the vaccines and their on time administration.

Find this type of content useful? Follow my blog for more of healthcare industry related content. #medicalcoding #medicalbilling #reimbursement

Posted in #reimbursement, EmblemHealth NY, Insurance, NY Providers, Training

EmblemHealth Commercial Plans: site of care change – adding 170 new injectable and infusion meds to the list

Posted on by KR2Medical Billing

Effective July 15, 2024- EmblemHealth will update their site of care policy and add 170 more injectable and infusion drugs to the list.

This change will apply to the commercial line of business and for all age groups.

The change is to help bring down the members’ cost sharing (out of pocket costs) and provide an access to the ongoing maintenance of infusion therapy.

The following is a partial list of these medications:

Via EmblemHealth

Note: for a full list of medications and the pdf version of site of care policy please visit – https://www.emblemhealth.com/providers/news/infusions-and-injectables-updates-policy-202404

These medications will still require prior authorization but will no longer be covered when administered in a hospital setting.

Instead the medications will be covered in the following place of service:

POS 11- Office

POS 12- Home

Ambulatory Infusion Suites- (POS 24, POS 49, or POS 12 with Modifier SS)

Exceptions for members that are receiving their first dosage may be requested with justifiable medical necessity.

Find this type of content useful? Subscribe to my blog for latest payer updates: reimbursement, medical billing and coding, policy changes, etc.