NY Providers – Page 10 – KR2 Medical Billing

EmblemHealth NY, NY Providers, Payer Updates

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

Posted on October 7, 2024 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.

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FidelisCare-concurrent prior auth update for family and group therapy services.
This update will apply to any dos of Jan 1, 2026 and thereafter. This update does not apply to SUD services/ providers that are certified as Article 32. 29-I providers are also excluded from the concurrent prior authorization requirenments. Services affected: Family Psychotherapy – CPT Code 90847 Group Psychotherapy – CPT Code 90853 FidelisCare members have 30… Read more: FidelisCare-concurrent prior auth update for family and group therapy services.
Healthfirst Pharmacy Update Contrast agent reimbursement
The following information applies to the members in the following plans: Managed Medicaid Plans and Personal Wellness Plans (HARP) Back in 2023, NYS DOH announced that there will be a change to the pharmacy benefits for MMC, HARP members- the pharmacy benefits will be covered but NYRx. This change was finally implemented in April 2025.… Read more: Healthfirst Pharmacy Update Contrast agent reimbursement
NYS Medicaid to cover TCM (Therapeutic Transcranial Magnetic Stimulation)
The information discussed below applies to straight NYS Medicaid members for the DOS 10/1/25 and effective for any DOS on or 11/1/25 and thereafter for any Managed Medicaid Members. What is TC? A non-invasive form of brain stimulation using magnetic pulses on specific areas of the brain. This therapy is used to improve the symptoms… Read more: NYS Medicaid to cover TCM (Therapeutic Transcranial Magnetic Stimulation)
HealthFirst Telehealth mental health modifier update
This update applies to HealthFirst following plan types: Medicaid, Personal Wellness Plan (HARP), and Medicaid Advantage. Which services are affected? Telehealth services done through a NY OMH licensed and or designated outpatient program. Please refer to OMH modifier and rate code chart here. To ensure the providers receive proper reimbursement, please make sure you go… Read more: HealthFirst Telehealth mental health modifier update
AETNA Commercial Plans: compression supplies non covered codes.
Please note that this policy update applies to the members that have commercial plan types. The affected codes: for any DOS on or after Jan 1st 2026, Aetna will consider the following codes for compression stockings to be a disposable supply and a standard benefit exclusion. Codes: For Texas Providers: These changes apply to fully… Read more: AETNA Commercial Plans: compression supplies non covered codes.

#reimbursement, BCBS (Various States), BCBS Empire NY, Cinga Insurance, EmblemHealth NY, HEDIS Measures, NY Providers, Training

HEDIS Measure: Immunizations for Adolescent

Posted on June 11, 2024June 11, 2024 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

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.

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#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 April 27, 2024 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:

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.

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