Category: Training

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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Posted in #reimbursement, #unitedhealthcare, Payer Updates, Payers and CPT reinbursement, Prior Authorization Insurance Carrier Updates, Training

UHC Community Health Texas- new billing workflow

Posted on by KR2Medical Billing

Are you a provider offering services to UHC Community Health dual eligible special need members? Then this blog post is for you!

As per recently passed bill: Texas House Bill 1open_in_new (Art. II, HHSC, Rider 32); there are new medical billing workflow that is in affect for any DOS 9/1/2025 and thereafter.

The following services will no longer be covered by Texas Health and Human Services Commission (HHSC).

Instead the providers would need to bill for any Medicare wrap around service to UnitedHealthcare Community Plan of Texas directly.

For any wrap around covered medications, including OTC- OptumRx will manage those.

Medicaid-covered services will switch from FFS to managed care billing based on the HHSC rate

Services provided through FFS for Medicaid-only beneficiaries, like pediatric nursing facility services, will not be affected

Some services and service would need a prior authorization.

For this the provider would need to go to UHCprovider.com and select Sign In at the top-right corner

  • Sign in to the portal using your One Healthcare ID and password
  • In the menu, select Prior Authorizations
  • In the Prior Authorization and Notification tool, scroll down to “Create a new notification or prior authorization request” and click Create New Submissions
  • Enter the required information and submit

If you need to find the list of the procedures and codes that require an auth please click here:

Listopen_in_new window- PDF

View all of the Rider 32 0rocedure codes and descriptions here: listingopen_in_new window

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