Category: #reimbursement

Posted in #reimbursement, #unitedhealthcare, Prior Authorization Insurance Carrier Updates

UHC Community Health Plan LTSS of DC: DME prior requirenments

Posted on by KR2Medical Billing

For some specific DME equipment, prior auth requirenments will align with durable medical equipment (DME) prior authorization requirements of the UnitedHealthcare® Dual Complete® Special Needs Plan (DSNP).

These requirenments take effect on 10/1/25 and apply to members with UnitedHealthcare Community Plan District of Columbia as well as integrated DSNP plans for Long-Term Care Services and Supports (LTSS).

Some of these DMEs are:

Patient lifts
Power wheelchairs
Respiratory support devices

Among others.

These prior authorization requirenments apply to the following codes:

To request an auth:

Phone: Call 888-702-2202

Fax: 866-968-7582. The fax form is available at Prior Authorization Forms on UHC website.

Or request the auth on the portal:

Sign in to the UnitedHealthcare Provider Portalopen_in_new with your One Healthcare ID

If you don’t have a One Healthcare ID, register now

From the left-hand tabs, select Prior Authorizations & Notifications

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Posted in #reimbursement, EmblemHealth NY, NY Providers, Payer Updates, Training, Updates

EmblemHealth/Connecticare/Molina Health update

Posted on by KR2Medical Billing

Are you a provider in CT or NY that serves EmblemHealth/Connecticare members-this blog post is for you!!!

Back in July of 2024, EmblemHealth announced and entered into an agreement with MolinaHealth to sell ConnectiCare (a company part of EmblemHealth).

In a Feb 2025, the sale was finalized.

So what does this mean to you as a provider?

EmblemHealth put together a reference table that the providers can utilize to check the plan/network information and which area that plan/network covers, plus description of the plans; ex deductible, copay, OON benefits, etc.

Image via EmblemHealth website.

Please visit here to view the PDF version of the whole document.

Molina also created a FAQs section that you can access from the same EmblemHealth website.

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Posted in #Medicare, #Medicareadvantage, #reimbursement, EmblemHealth NY, NY Providers, Payer Updates, Pharmacy (Various Insurance Payers), Training

Emblem Health new Specialty Meds/Pharmacy Policy

Posted on by KR2Medical Billing

Effective 7/14/25 there is a new specialty pharmacy policy will apply to all of Emblem Health lines of busines: commercial, Medicare, medicaid.

Image via emblemhealth

This policy applies to all outpatient providers in the following place of service: outpatient hospital, physician office,home of the member and ambulatory infusion.

Takeaways:

1. According to this policy the providers need to contact the respective specialty pharmacy to request prior auth and are only allowed to bill for specialty medications administration NOT the medication itself.

2. The Specialty Pharmacy will be allowed to bill Emblem health under the member’s medical benefit and receive reimbursement.

Image via EmblemHealth

3. For any Medicaid EmblemHealth plan- the medicatin codes must be on Medicaid Fee Schedule. If the code is not listed it will not be reimbursed.

Exclusion: this policy does not apply to home infusion providers.

For a full list of specialty medications please visit Emblem Health for more information and a PDF version of the policy

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