Posted in EmblemHealth NY, NY Providers, Training, Updates

EmblemHealth NY Medicaid and HARP members: Non-Invasive Prenatal Trisomy Screening Expanded!

Effective 11/01/2021 coverage of non-invasive prenatal trisomy screening using cell-free fetal DNA (deoxyribonucleic acid) has been expanded to include pregnant members age 30 and older.

This benefit also will include twin pregnancies, but not higher multi-gestational pregnancies


Consistent with current policy, non-invasive prenatal trisomy screening will continue to be covered when at least one of the following criteria is met:

  • Either parent has a family history of aneuploidy in a first* or second** degree relative.
  • Standard serum screening or fetal ultrasonographic findings indicate an increased risk of aneuploidy.
  • Parent(s) have a history of a previous pregnancy with a trisomy.
  • Either parent is known to have a Robertsonian translocation.

Definitions:

*First degree relatives: Parents, children, siblings
** Second degree relatives: Grandparents, aunts and uncles, nieces and nephews, and grandchildren


Note: This is an update to the October 2014 Medicaid Update article titled NYS Medicaid Now Covers Non-invasive Prenatal Testing for Trisomy 21, 18 and 13.

You can find the updated version of this policy (NY Medicaid) here.  


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Posted in BCBS Empire NY, Updates

Empire BCBS (NY) and SOMOS IPA Utilization Management

Reminder that effective 10/01/2020- SOMOS IPA will assume the administrative functions for several Empire HealthPlus Plans:

Medicaid Managed Care (MMC)

Health and Recovery Plan (HARP)

Child Health Plus (CHPlus)

Essential Plan programs

SAMPLE EMPIRE SOMOS IPA CARDS:

FRONT OF THE CARD
BACK OF THE CARD

Contacting SOMOS for patient Eligibility, benefits and authorizations: OON and IN providers

Credentialing process:
• SOMOS IPA providers: SOMOS will handle all credentialing for its participating providers. This
includes the submission of any demographic changes or terminations.
• Non-SOMOS IPA providers: Providers who are not contracted with the IPA must continue to follow the Empire processes.

For more information please click here.

Posted in Insurance, My services, Training, Updates

UHC Community Health (NY) Specialist Referral Requirements, 03/01/2021

These Specialist Referral Requirements will apply to the following:

  • UnitedHealthcare Community Plan for Families (Medicaid)
  • UnitedHealthcare Community Plan Wellness 4 Me (HARP) 
  • UnitedHealthcare Community Plan ChildHealthPlus (CHP)

This new change will take effect on 03/01/2021. The referrals will need to be generated by the member’s PCP. Primary Care Providers can begin to request a referral for any date on 03/01/2021 and thereafter.

Between now and 03/01/2021, in network specialists will continue to get reimbursed as usual.

The following services that WILL NOT REQUIRE A REFERRAL:

  • Women´s Health Care
  • Family Planning 
  • HIV and STI Screening
  • Eye Care (subject to benefit limits in member handbook)
  • Dental Care
  • Behavioral Health – (Mental Health and Substance Use)
  • Smoking Cessation
  • Maternal Depression Screening
  • Services rendered in any emergency room or network urgent care center
  • Physician services for emergency/unscheduled admissions
  • Any services from inpatient consulting physicians
  • Radiologist, Pathologist, Anesthesia, etc. Providers that are part of inpatient hospital care or surgical teams do not need referrals
  • A specialist who has arranged to act as the member’s PCP does not need a referral for him or herself. Please see FAQs for additional information. Any other services for which applicable laws and regulations do not allow us to impose a referral requirement.

ANY services that are NOT LISTED above will REQUIRE a REFERRAL from the PCP to the IN-Network Specialist.

If you have any questions, please call: 888-362-3368. 

#UHC #referral #specialists #PCP #NYproviders #communityhealth #HARP #nymedicaid