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PROVIDER PORTAL FREQUENTLY ASKED QUESTIONS

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 * 
 * Provider ResourcesProvider Resources
    * Key Resources
   
   Key Resources Frequently Asked Questions News and Updates Newsletters
   Directory Member ID Cards Improving Patients' Experiences Access &
   Availability Standards Network Laboratories Plans with No Referrals Urgent
   Care Center Locations
   Provider Toolkit Welcome materials, guides, and forms
   Our Companies, Lines of Business, Networks, and Benefit Plans Bridge Program
   Commercial Networks and Benefit Plans Medicaid, HARP, and CHPlus
   (State-Sponsored Programs) Medicare Advantage Plans Credentialing Join Our
   Network
   Learning Online/ Required Trainings Provider Portal Materials Cultural
   Competency Continuing Education and Resources Medicaid Cultural Competency
   Certification Special Needs Plan Model of Care Medicare Fraud, Waste, and
   Abuse State-Sponsored Programs Veradigm Webinars Referral Quick Guide
   For Your Members Resources to share with your members
   Neighborhood Care Find a center near you, view classes and events, and more
   
   
   BRIDGE PROGRAM
   
   Find important information about the EmblemHealth Bridge Program
   
   Search Our Bridge Program Page
 * Clinical CornerClinical Corner
    * UM and Medical Management
    * Care Management Programs
   
   UM and Medical Management Preauthorization Lists Provider Portal Transaction
   Resources Plans with No Referrals Preauthorization Contacts Utilization
   Management News
   Care Management Programs Care Management
   Vendor-Managed Utilization Management Programs Behavioral Health Services
   Durable Medical Equipment Pharmacy Services and Specialty Pharmacy Oncology
   Management Radiology-Related Programs and Privileging Rules for
   Non-Radiologists Spine and Pain Management
   Quality Improvement Programs and Resources Clinical Practice Guidelines
   MD Perspectives Hear from our Medical Directors
   Medical Policies EmblemHealth Medical Policies ConnectiCare Medical Policies
   Pharmacy Pharmacy News Formularies Pharmacy Medical Preauthorization List
   Enterprise Pharmacy Policies New Century Health — Medical Oncology Policies
   UM and Medical Management Pharmacy Services
   
   
   QUALITY IMPROVEMENT
   
   Find our Quality Improvement programs and resources here.
   
   Search Our Quality Improvement Page
 * Claims CornerClaims Corner
    * Claims Resources
   
   Claims Resources Fee Schedule Updates Hospital Readmission Policy Electronic
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   Submissions Claims Contacts EmblemHealth Guide for Electronic Claims
   Submissions Timely Submissions Claims Submissions
   Reimbursement Policies Consolidated Appropriations Act/No Surprise Billing
   Information Payment processes unique to our health plans
   Payment Integrity Policies How we pursue payment accuracy
   Coding EmblemHealth Guide for NPIs and Taxonomy Codes
 * Provider ManualProvider Manual
   Overview Directory Credentialing Member Identification Cards Member Policies
   and Rights 2023 Provider Networks and Member Benefit Plans
   Access to Care and Delivery System Health Promotion and Care Management
   Pharmacy Services EmblemHealth Spine Surgery and Pain Management Therapies
   Program Durable Medical Equipment Home Health Care
   SNF IRF LTAC Medical Transportation Procedures Utilization and Care
   Management Clinical Practice Guidelines Radiology Program Outpatient
   Diagnostic Imaging Privileging View All
   
   
   PROVIDER MANUAL
   
   Find the specific content you are looking for from our extensive Provider
   Manual.
   
   Search the Provider Manual
 * Dental CornerDental Corner
    * Resources for Dental Providers
   
   Resources for Dental Providers Benefits to Participation in Dental Network
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 * Provider Resources
    * Key Resources
   
   Provider Resources
   Key Resources Frequently Asked Questions News and Updates Newsletters
   Directory Member ID Cards Improving Patients' Experiences Access &
   Availability Standards Network Laboratories Plans with No Referrals Urgent
   Care Center Locations
   Provider Toolkit Welcome materials, guides, and forms Our Companies, Lines of
   Business, Networks, and Benefit Plans Bridge Program Commercial Networks and
   Benefit Plans Medicaid, HARP, and CHPlus (State-Sponsored Programs) Medicare
   Advantage Plans Credentialing Join Our Network
   Learning Online/ Required Trainings Provider Portal Materials Cultural
   Competency Continuing Education and Resources Medicaid Cultural Competency
   Certification Special Needs Plan Model of Care Medicare Fraud, Waste, and
   Abuse State-Sponsored Programs Veradigm Webinars Referral Quick Guide
   For Your Members Resources to share with your members Neighborhood Care Find
   a center near you, view classes and events, and more
   
   
   BRIDGE PROGRAM
   
   Find important information about the EmblemHealth Bridge Program
   
   Search Our Bridge Program Page
 * Clinical Corner
    * UM and Medical Management
    * Care Management Programs
   
   Clinical Corner
   UM and Medical Management Preauthorization Lists Provider Portal Transaction
   Resources Plans with No Referrals Preauthorization Contacts Utilization
   Management News Care Management Programs Care Management
   Vendor-Managed Utilization Management Programs Behavioral Health Services
   Durable Medical Equipment Pharmacy Services and Specialty Pharmacy Oncology
   Management Radiology-Related Programs and Privileging Rules for
   Non-Radiologists Spine and Pain Management
   Quality Improvement Programs and Resources Clinical Practice Guidelines
   Medical Policies EmblemHealth Medical Policies ConnectiCare Medical Policies
   MD Perspectives Hear from our Medical Directors
   Pharmacy Pharmacy News Formularies Pharmacy Medical Preauthorization List
   Enterprise Pharmacy Policies New Century Health — Medical Oncology Policies
   UM and Medical Management Pharmacy Services
   
   
   QUALITY IMPROVEMENT
   
   Find our Quality Improvement programs and resources here.
   
   Search Our Quality Improvement Page
 * Claims Corner
    * Claims Resources
   
   Claims Corner
   Claims Resources Fee Schedule Updates Hospital Readmission Policy Electronic
   Claims Policy In-Office Testing List
   Submissions Claims Contacts EmblemHealth Guide for Electronic Claims
   Submissions Timely Submissions Claims Submissions
   Reimbursement Policies Consolidated Appropriations Act/No Surprise Billing
   Information Payment processes unique to our health plans Payment Integrity
   Policies How we pursue payment accuracy
   Coding EmblemHealth Guide for NPIs and Taxonomy Codes
 * Provider Manual
   Provider Manual
   Overview Directory Credentialing Member Identification Cards Member Policies
   and Rights 2023 Provider Networks and Member Benefit Plans
   Access to Care and Delivery System Health Promotion and Care Management
   Pharmacy Services EmblemHealth Spine Surgery and Pain Management Therapies
   Program Durable Medical Equipment Home Health Care
   SNF IRF LTAC Medical Transportation Procedures Utilization and Care
   Management Clinical Practice Guidelines Radiology Program Outpatient
   Diagnostic Imaging Privileging View All
   
   
   PROVIDER MANUAL
   
   Find the specific content you are looking for from our extensive Provider
   Manual.
   
   Search the Provider Manual
 * Dental Corner
    * Resources for Dental Providers
   
   Dental Corner
   Resources for Dental Providers Benefits to Participation in Dental Network
   Join Our Dental Network
   Welcome Dental Providers Find a Dentist
   Dentists Contact Us Update Your Practice Records
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PROVIDER PORTAL FREQUENTLY ASKED QUESTIONS

Last Reviewed Date: 2023/11/02

 1. Home
 2. Provider
 3. Provider Portal Frequently Asked Questions




PORTAL IMPROVEMENTS


WHAT IMPROVEMENTS HAVE BEEN MADE TO THE PORTALS?



EmblemHealth and ConnectiCare continue to update the provider portals to make it
easier to use and to simplify how we work together:

 * In April 2023, our provider portals will introduce a new way to automate and
   simplify preauthorization transactions.
 * To make it easier for you to send us documents using the provider portal to
   support preauthorization requests and notifications, we increased the file
   size for uploading supporting documentation for all transactions. You can now
   upload 25 MB per file.
 * Care Plans developed through our Care/Case Management programs are available
   in the Member Management section on the Member Details page.


SITE ACCESS


I AM TRYING TO SIGN IN AND HAVE BEEN LOCKED OUT. WHAT DO I DO?



You can wait 30 minutes and try to enter your password again or use the “Forgot
Password” option to reset your password without waiting. 


I HAVE NEVER USED THE SITE BEFORE. HOW DO I REQUEST A USERNAME AND PASSWORD?



Joining Existing Group
If you have joined a practice, group, or facility (jointly organization) that
already has a relationship with our companies, you will be able to reach out to
your Portal Administrator or Office Manager to set up access to the Provider
Portal. 

If you do not know your Portal Administrator or Office Manager, please use the
Provider Portal Registration Form and we will let you know who they are or help
you set one up if none are available.

Newly Contracted Provider
If you, your practice, facility, etc., have signed a brand-new contract with us,
or have activated a new Tax ID, we will reach out to your designated
Administrator. They will be sent a single registration code per Tax ID to unlock
access for the affiliated providers and users. Your Administrator/Office Manager
will then be able to set you up with access to our Provider Portal. The portal
does not allow bulk uploads of new Tax IDs or new users.
 

If you believe you should have received a communication but are unable to find
it, please reach out to Provider Customer Service, Monday to Friday from 8 a.m.
to 6 p.m., and one of our agents will be happy to help you with getting a new
registration code to complete your Provider Portal access setup:
 

EmblemHealth: 866-447-9717
ConnectiCare Commercial: 860-674-5850 or 800-828-3407
ConnectiCare Medicare: 877-224-8230

EmblemHealth Dental Provider

If you, your practice, facility, etc., have signed a brand-new contract with us,
or have activated a new Tax ID, please call us at one of the numbers below and
we will give you a single registration code per Tax ID to unlock access for the
affiliated providers and users. Your Administrator/Office Manager will then be
able to set you up with access to our Provider Portal. The portal does not allow
bulk uploads of new Tax IDs or new users.

 * 212-501-4444 in New York City
 * 800-624-2414 outside of New York City

Non-Participating Providers

If you have ever submitted a claim and want to request a provider portal account
now, fill out the short Provider Portal Registration Form.

Billing Company Staff

If you do not already have a user account and you need to do work for a
practice, group, or facility (jointly organization) that already has a
relationship with our companies, please contact their Portal Administrator or
Office Manager to set up access a to the Provider Portal account for you.  

If you do not know the Portal Administrator or Office Manager for a given Tax
ID, please use the Provider Portal Registration Form and we will let you know
who they are.

If you already have an account linked to multiple clients, use the Provider
Portal Registration Form to request your new client’s TIN to be added to your
existing account. 


HOW DO I FIND MY PORTAL ADMINISTRATOR OR OFFICE MANAGER?



Usually, the person who oversees the patient financial services (PFS) workflow
is responsible for being the key administrator  – the person who maintains and
obtains insurance web portal access and assigns rights to the portal. 

Where an organization had a user(s) in the Clinical Staff Role, but did not have
a registered Portal Administrator or Office Manager, the Clinical Staff’s
permissions were updated to Portal Administrator or Office Manager to ensure
someone has access to add new users.

Ask your supervisor if you don’t know your Office Manager. If they do not know,
please contact Provider Customer Service, Monday to Friday from 8 a.m. to 6 p.m.
for assistance:
 

EmblemHealth: 866-447-9717
ConnectiCare Commercial: 860-674-5850 or 800-828-3407
ConnectiCare Medicare: 877-224-8230


WHAT CAN MY OFFICE MANAGER DO FOR ME?



Your Office Manager for your organization can perform the following (but not
limited to):

 * Create an account
 * Change an existing account’s access 
 * Update account permissions to create referrals or benefit extensions 


DOES EVERY USER FROM MY OFFICE REQUIRE SEPARATE SIGN-IN CREDENTIALS?



Yes. Each user will require their own username and password. They will also need
a unique email address to authenticate their access. 


CAN AN ADMINISTRATOR/OFFICE MANAGER SEE ALL PROVIDERS LINKED TO A TAX ID?



The portal does not use company-defined provider IDs.

The new portal works at a Tax ID level. Once the Administrator/Office Manager
has access to a Tax ID, all providers affiliated with that Tax ID will be
available to them. They may then decide which users may conduct business on
behalf of each specific provider.


CAN A USER BE ASSIGNED MORE THAN ONE TYPE OF ACCESS?



Type of access (role) is defined at the Tax ID level. Only one type of access
may be assigned per user per Tax ID in the new portal. Different Tax IDs may
have different types of access assigned to a single user. See:
 

EmblemHealth’s Role Permissions Table

ConnectiCare’s Role Permissions Table


FOR IPAS/FACILITIES/HOSPITALS WITH MULTIPLE PROVIDERS, CAN A USER HAVE ACCESS TO
SEE ALL PROVIDER CLAIMS, PREAUTHORIZATIONS, ETC.?



Yes. Users can be provided access at the Tax ID level and have access to
multiple Tax IDs. This should give full access to all claims and authorizations
across all their participating providers.
 

While not recommended, if a single user does want separate accounts to
differentiate their work across Tax IDs or to have more than one type of access
for a Tax ID, they must use a unique email address for each account.


FOR GROUPS/FACILITIES THAT HAVE BOTH MEDICAL AND DENTAL PROVIDERS, DO USERS HAVE
ACCESS TO BOTH THROUGH ONE USERNAME?



Yes. Only a single username is required to see all data – medical and dental.


WHAT IS THE TIMEOUT LIMIT?



User default timeout after inactivity is 15 minutes. A warning message will
appear 30 seconds before the 15-minute mark and access to the site is ended.


WHAT URL SHOULD I USE TO SIGN INTO THE NEW PROVIDER PORTAL?



We recommend that you access our sites using the “Sign In” links on our public
websites for providers.

For EmblemHealth, go to: emblemhealth.com/providers/resources/provider-sign-in

For ConnectiCare, go to: provider.connecticare.com/cciprovider/providerlogin


DO I NEED TO USE A PARTICULAR BROWSER TO ACCESS THE NEW PROVIDER PORTAL?



Make sure you are using a supported browser such as Google Chrome or Microsoft
Edge when using our secure portal. Other browsers may not be supported. If you
use an unsupported browser, you will be unable to access the site. The new site
cannot be used with Internet Explorer.


HOW DO I SIGN IN TO THE PORTALS? DO I NEED A NEW USER ID AND PASSWORD (ALSO
REFERRED TO AS PIN) TO SIGN IN?



You need your own User ID as you are not able to share (only one person per User
ID moving forward).


Each user will need to create a new username and password (also referred to as
PIN). You can create this on your own using the “Sign In” link on our public
websites for providers. 

For EmblemHealth, go to: emblemhealth.com/providers/resources/provider-sign-in

For ConnectiCare, go to: provider.connecticare.com/cciprovider/providerlogin


The username and password you create will work for both EmblemHealth’s and
ConnectiCare’s Provider Portals.

Each portal account must have a unique email address to support multi-factor
authentication. You may not share email addresses across different users.

You will use this email when you set up your password for the first time. You
will also need your email if you ever need to retrieve/reset your password and
username in the future.


DO USERS NEED A SEPARATE SIGN-IN FOR EACH INDIVIDUAL HOSPITAL, IPA, FACILITY,
GROUP, ETC.?



No. One of the key improvements of this portal is the ability to consolidate all
portal access needs for a user under a single email address (username). 
 

For example, an individual who works at six hospitals, manages two faculty
practice plans, and has part-time responsibilities for an outpatient offsite
clinic will only need one account. 
 

Portal access is based on the Tax ID, not the individual provider/location. In
the example above, if all of the hospitals, faculty practice plans, and the
outpatient clinic all use the same Tax ID, only the initial account set-up will
be needed. If, however, each uses a different Tax ID and the user will use nine
sign-ins, they will need to follow the account consolidation instructions to
pull all information into the one account.


WHAT IS MULTI-FACTOR AUTHENTICATION?



Multi-factor authentication is an industry-standard safety mechanism used to
confirm that secure websites are being accessed only by a rightful and
authorized user.
 

To accomplish this, our new Provider Portals require a secondary method – a
unique email address – to validate the user’s identity. 
 

We use the email address on the user account to send out a verification code
that needs to be entered after the sign-in to proceed with accessing the
system. 
 

This account validation will be triggered every three months or if we detect
that you have switched computers or devices that you use to access the Provider
Portal. 
 

This step should take only a few seconds and helps us significantly improve the
security of our systems and the confidential information of the communities we
serve.


IF I WORK WITH BOTH EMBLEMHEALTH AND CONNECTICARE, CAN I CONNECT THESE ACCOUNTS?



Yes. Once you consolidate the accounts, you will be able to use one account for
both EmblemHealth and ConnectiCare. Access will be through one account, and you
will no longer need to switch back and forth.


AS A NON-PARTICIPATING PROVIDER, HOW CAN I SET UP A PROVIDER PORTAL ACCOUNT?



If you have ever submitted a claim and want to request a provider portal account
now, fill out the short Provider Portal Registration Form.


TRAINING


WHAT KIND OF TRAINING MATERIALS ARE AVAILABLE?



We posted the following training materials for your use:

 * Micro-videos 
 * PowerPoint presentations
 * Quick Reference Guides (Job-Aids)

EmblemHealth Training materials

ConnectiCare Training materials


WHAT CAN I LEARN FROM THE QUICK REFERENCE GUIDES (JOB-AIDS) AND MICRO-VIDEOS?



Training material will cover a range of topics including:

 * The sign-in process
 * Portal navigation
 * How to set different user roles
 * Downloading reports to Excel
 * Managing patient care using referral and preauthorization transactions
 * Finding claims information, checking images, and Explanations of Payment
   (EOPs)
 * And much more


WHO CAN I GO TO FOR QUESTIONS ON ANY TRAINING MATERIAL?



Please contact our Provider Customer Service, Monday to Friday from 8 a.m. to 6
p.m.:

EmblemHealth: 866-447-9717
ConnectiCare Commercial: 860-674-5850 or 800-828-3407
ConnectiCare Medicare: 877-224-8230


ELIGIBILITY/BENEFITS


CAN I GET PRINTABLE BENEFIT SUMMARIES FOR ALL MY MEMBERS?



Benefit summaries are displayed on the portals and can be printed.


CAN I REQUEST BENEFIT EXTENSIONS FOR EMBLEMHEALTH PLAN, INC. (FORMERLY GHI)
MEMBERS FOR PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, ALLERGY
TREATMENTS, AND VISION SERVICES (ORTHOPTICS) ON THE PROVIDER PORTAL?



Yes. You can do so by going to “Preauthorization” on the menu, then select
“Request Benefit Extension.”


CAN I LOOK UP ELIGIBILITY INFORMATION FOR DATES IN THE PAST?



Yes. By going to “Eligibility” under the Member Management menu, you may see
eligibility search results for the last two years.


CAN I LOOK UP ELIGIBILITY INFORMATION FOR A DATE IN THE FUTURE IF I AM
SCHEDULING AN APPOINTMENT OR ELECTIVE ADMISSION?



When you look up a member, you will see the Coverage Start Date for the member.
Typically, this will be early in the year (e.g., Jan. 1). Then the “Coverage End
Date” is a default date that is something like “12/31/9999.”

The Coverage End Date is open-ended because we don’t know if/when a member will
renew their policy, change jobs, stop paying their premium, etc. That is why
their end date is always open.

Payment is always subject to a member’s eligibility on the applicable date(s) of
service.


WHEN SEARCHING FOR A PATIENT WITH A HYPHENATED NAME, DO YOU ENTER THE HYPHEN?



The portal is set up to conduct partial name searches; an exact match to a full
name with a hyphen is not needed. A minimum of two characters has to be entered.


MEMBER MANAGEMENT


CAN I SEE THE MEMBER’S ACTUAL ID CARD IMAGE? CAN I SEE BOTH THE FRONT AND BACK
OF THE CARD?



The ID card displayed is the actual ID card and both the front and back are to
be shown. When an actual ID card is not available, we will show a temporary ID
card.


HOW DO I KNOW IF I AM IN-NETWORK FOR A MEMBER?



How do I know if I am in-network for a member?

The easiest way to see if you are in-network for a member is to use the Check
Provider Network Status look-up tool in the Provider Portal.

Under the Member Management menu, select Eligibility or Check Provider Network
Status.

 * Search for the member. On the “Member Details” page, click the Check Provider
   Network Status button.
 * Clicking the button carries the member’s information forward to a new screen.
   Search for the  provider. (Network checks are limited to the provider
   themselves and their authorized portal Users.)
 * The search results display the provider’s network status for that member in
   the right-most column in the results table.  


WHICH MEMBERS’ CARE PLANS WILL I BE ABLE TO SEE IN THE PROVIDER PORTAL?



Starting Aug. 26, 2022, care plans developed through any of our Care/Case
Management Programs will be made available on our provider portals. Plans with
highly sensitive information will not be posted. You will need to request plans
with sensitive information directly from the applicable Care/Case Management
team.

If you have a member who does not have a care plan, and you’d like to partner
with our Care/Case Management team to develop one, please reach out to the
applicable team.

Care/Case Management Teams

EmblemHealth: Call 800-447-0768 Monday through Friday from 9 a.m. to 5 p.m. See
our Care Management Programs page for program descriptions and ways we can
support you and your patients.

ConnectiCare: Call 800-390-3522 Monday, Thursday, and Friday from 8 a.m. to 4
p.m. or Tuesday and Wednesday from 8 a.m. to 7:30 p.m.


HOW DO I FIND MY MEMBER’S CARE PLAN IN THE PROVIDER PORTAL?



To review, print, or download a member’s care clan:

 1. Click the “Member Management” tab at the top of the homepage and select
    “Eligibility” from the dropdown menu.
 2. Search for the member whose care plan you would like to review and click the
    hyperlinked member ID.
 3. Once on the “Member Details” page, click the “View Care Plan” button at the
    top of the page to view the care plan.


HOW DO I ADD INFORMATION OR SUBMIT A CORRECTION TO THE CARE PLAN?



To submit an update to a member’s care plan on the Care Plan Details page:

 1. Click the “Send a Comment or Question” button.
 2. Search for and select a provider to be the sender of the message.
 3. "Care Management” will default as the category for your message.
 4. Choose the “Provider Portal Care Plan Question” subcategory for your
    question.
 5. Click the priority field and select Urgent, High, Medium, or Low.
    
        Note: The turnaround times to see your update(s) post are:
    
    * Urgent: 1 business day
    * High: 2 business days
    * Medium: 4 business days
    * Low: 7 business days
    
     

 6. Click the “Message Content” field to enter your message


HOW DO I CONTACT THE CARE TEAM IF I HAVE QUESTIONS ABOUT A POSTED CARE PLAN OR
NEED A COPY OF A PLAN WITH SENSITIVE INFORMATION THAT IS NOT ON THE PORTAL?



If you have questions about a care plan or need a plan that has sensitive
information that cannot be posted to the portal, please contact our Care Team.
They are ready to assist you.

On the Care Plan Details page:

 1. Click the “Send a Comment or Question” button.
 2. Search for and select a provider to be the sender of the message.
 3. "Care Management” will default as the category for your message.
 4. Choose the “Provider Portal Care Plan Question” subcategory for your
    question.
 5. Click the priority field and select Urgent, High, Medium, or Low.
    
        Note: The turnaround times to see your update(s) post are:
    
    * Urgent: 1 business day
    * High: 2 business days
    * Medium: 4 business days
    * Low: 7 business days
    
     

 6. Click the “Message Content” field to enter your message.

Responses to inquiries will be made via phone or email, not the Provider Portal.
If the portal is not available, you may call:

EmblemHealth: 800-447-0768 Monday through Friday from 9 a.m. to 5 p.m.

ConnectiCare: 800-390-3522 Monday, Thursday, and Friday from 8 a.m. to 4 p.m. or
Tuesday and Wednesday from 8 a.m. to 7:30 p.m.


HOW DO I REFER A MEMBER TO CARE MANAGEMENT?



To refer a member to one of our Care/Case Management programs:

EmblemHealth: See our Care Management Programs page for program descriptions,
ways we can support you and your patients, and program-specific contact
information. If you need general assistance, you can call 800-447-0768 Monday
through Friday from 9 a.m. to 5 p.m.

ConnectiCare: Call 800-390-3522 Monday, Thursday, and Friday from 8 a.m. to 4
p.m. or Tuesday and Wednesday from 8 a.m. to 7:30 p.m.


MANAGING MEMBERS – PCP MEMBER PANEL REPORT


CAN I RUN A PCP MEMBER PANEL REPORT?



Yes. You are able to run a PCP Member Panel Report by clicking on the "Member
Management" tab in the menu and then the PCP Member Panel Report sub-menu. 
 

The report will only include active members.


CAN I RUN PCP MEMBER PANEL REPORTS FOR EACH OF THE PCPS IN MY PRACTICE?



Yes. You can run a report for each PCP you are affiliated with. Once on the PCP
Member Panel Report page, you can search by a specific provider to generate
their report.


CAN I DOWNLOAD A PCP MEMBER PANEL REPORT INTO EXCEL? HOW LONG DOES IT TAKE?
WHERE CAN I FIND THE REPORT?



Yes. You will be able to generate a PCP Member Panel Report that may be exported
to Excel. 
 

Note that documents can take up to 30 minutes from when you select “Export to
Excel” before appearing in the Documents tab.


CLAIMS


HOW FAR BACK WILL I BE ABLE TO FIND CLAIMS INFORMATION AND EXPLANATIONS OF
PAYMENT (EOPS)/REMITTANCES FOR MY CLAIMS?



Users will be able to search for claims submitted within the last two years.
Search results, however, will only be displayed showing 90 days of information
at a time. 
 

Explanation of Payment (EOP)*/remittance information will be available in the
Claims Details page. If there is no remittance information available, then there
will be a message stating there are no records found. 
 

Check images will be available for the past two (2) years. 
 

V-cards are not available as separate images but will be part of the Explanation
of Payment documents.
 

If information is needed for a prior time period or you can’t find what you
need, you may submit a request through the Message Center using the Ask a
Question option. You may also contact Customer Service, Monday to Friday from 8
a.m. to 6 p.m.: 
 

EmblemHealth: 866-447-9717
ConnectiCare Commercial: 860-674-5850 or 800-828-3407
ConnectiCare Medicare: 877-224-8230
 

*Explanations of Benefits (EOBs) are documents sent to members. Providers are
given Explanations of Payment (EOPs).


CAN I EXPORT MY CLAIMS INFORMATION TO AN EXCEL SPREADSHEET?



Yes. Claim results, including payment information, can be exported to Excel.
After exporting the results, you can download the CSV file from the document
center. The document will be available only for you.


WHERE CAN I FIND COORDINATION OF BENEFITS (COB) INFORMATION?



Coordination of Benefits (COB) may be found in the Additional Insurance section
of the Member Details Page returned on a member eligibility search.


PREAUTHORIZATION


DO I HAVE ACCESS TO THE PREAUTHORIZATION CHECK TOOL?



Yes. You can use the Preauthorization Check Tool to check for authorization
requirements across our membership.  
 

The Tool will indicate whether preauthorization is needed and from whom. The
tool should not be used to determine benefit coverage. The tool does not offer
tracking numbers or trackable trail showing the outcome of a given search. 
 

In contrast, Referrals, Preauthorization Requests, ER Admission Notifications,
and Newborn Notifications do provide a transaction tracking number.


CAN MULTIPLE CPT CODES BE ENTERED ON A SINGLE PREAUTHORIZATION REQUEST?



Yes. You can add multiple service lines to a single preauthorization request
each with its own CPT code.


WILL I BE ABLE TO SUBMIT CLINICAL DOCUMENTATION TO SUPPORT MEDICAL NECESSITY
DETERMINATIONS?



Yes. You can submit any kind of clinical documentation needed to support the
preauthorization request  while creating the request. At the end of the process,
you will see an “Add Supporting Documentation” screen.

Preauthorization requests that trigger the collection of additional clinical
information have an Attach File option where you can submit medical records or
other supporting documentation you would like us to consider.  You may now send
up to 25 MG per document.

You may also go back into the case after it is submitted to upload additional
information.

We encourage providers to submit information via the portal in place of sending
information via fax. Sending information via fax can delay the review process.

To submit additional information after a request is submitted, select
“Preauthorization” from the menu and “Search Preauthorization” from the
sub-menu. You can search for and find your previously submitted preauthorization
then click on the hyperlinked Reference ID. This should take you to the
Preauthorization Details page and you can click the “Add Supporting
Documentation” button to add attachments. Note that if the Reference ID is not
hyperlinked yet, please check back in a few hours as preauthorization details
are not yet available.


IF THE PERSON WHO CREATES THE PREAUTHORIZATION REQUEST IS NOT AVAILABLE, CAN
ANYONE ELSE ACCESS AND FOLLOW UP ON THE TRANSACTION?



If the user who created the original preauthorization request is not available,
then any other user having affiliation to the same Tax ID(s) as the original
creator or an affiliation to the same Tax ID as the requested servicing
provider, and has a role of Administrator/Office Manager or Clinical Staff, will
be able to search for the preauthorization request.


CAN YOU ADD ADDITIONAL UNITS/VISITS TO A PREAUTHORIZATION REQUEST?



Once the preauthorization request is submitted, it cannot be changed using the
portal screens. The user may, however, upload additional documents to the
request and call the Utilization Management department to discuss the changes.


WHAT END DATE SHOULD BE SELECTED FOR A PREAUTHORIZATION REQUEST? HOW FAR OUT CAN
THE END DATE BE?



The user can choose the service dates for the preauthorization request. The
service dates must coincide with the member’s coverage dates. 
 

The service end date cannot be more than 180 days from the request date.


FOR PROVIDERS WHO HAVE A SUB-SPECIALTY, HOW IMPORTANT IS IT FOR THE ADDRESS AND
SPECIALTY TO MATCH?



The address selected must match with the sub-specialist’s Tax ID and NPI. It is
a combination of these three elements (address, Tax ID, and NPI) that are
critical for processing claims, preauthorization requests, and referral
transactions.


WHY HAVE EMBLEMHEALTH AND CONNECTICARE CHOSEN TO AUTOMATE SOME OF THE
PREAUTHORIZATION TRANSACTIONS?



By automating our processes and collecting information up front, we strive to
provide faster, more consistent responses to your review requests. In some
cases, we may be able to provide approval during the initial transaction.
Automation via our portal will help reduce or eliminate the number of follow-up
communications currently needed to make an informed medical necessity
determination.




WHEN WILL THE NEW AUTOMATION BE AVAILABLE?



We will introduce automation over time. You should start to see requests for
additional information in April 2023.


HOW WILL THE AUTOMATION WORK?



Submit requests and notifications through the provider portals following the
same steps you use today. At the end of applicable transactions, you will be
prompted to provide additional information. You will be taken to a new set of
screens where you will:

 * Check off boxes next to statements that apply to your patient’s needs.
 * Click icons to open windows where you can provide additional details.
 * Upload additional documents if you have not done so earlier.


REFERRALS


DO THE NEW YORK STATE SPONSORED PROGRAMS NEED REFERRALS?



As of January 1, 2023, referrals are no longer needed for Enhanced Care
(Medicaid), Enhanced Care Plus (HARP), and Child Health Plus (CHPlus), and
Essential Plan members.


WILL MY REFERRAL BE SENT TO THE SERVICING PROVIDER?



The referral will not be “sent,” but all referrals submitted within the last 24
months will be available to the servicing provider on the Provider Portal. 
 

Referrals submitted by means other than portal, such as by fax or phone, will
take some time to be seen in the portal.


I DO NOT HAVE ADMINISTRATIVE STAFF AVAILABLE EVERY DAY; WILL WE STILL BE ABLE TO
ENTER A REFERRAL FOR A DATE THAT HAS PASSED?



Yes. Referrals may be backdated up to 30 days to facilitate member access to
care.


WILL PROVIDER IDS BE NEEDED FOR REFERRAL TRANSACTIONS?



No. The portal will not use company-defined provider IDs.

The portal uses the providers’ names and NPIs to identify them.


NOTIFICATIONS


WILL I BE ABLE TO ENTER NOTIFICATIONS REGARDING EMERGENT INPATIENT ADMISSIONS OR
FOR MATERNITY/NEWBORN CASES?



Yes, you will be able to enter emergent inpatient admission notifications or
maternity/newborn cases using the “Create Emergent Inpatient Admission
Notification” tab on the menu.

For EmblemHealth’s delegated membership, you will need to notify the delegated
entity directly.

While you cannot submit elective inpatient admission notifications for delegated
members through our Provider Portal, you will be able to identify if the member
falls under a delegated arrangement and will be provided with instructions for
contacting the correct organization.

Note: Starting April 1, 2023, Montefiore CMO will no longer be delegated to
manage any EmblemHealth members. All notifications should be made directly to
EmblemHealth.


WHY HAVE EMBLEMHEALTH AND CONNECTICARE CHOSEN TO AUTOMATE SOME OF THE CONCURRENT
REVIEW TRANSACTIONS TRIGGERED BY THE EMERGENT INPATIENT ADMISSION NOTIFICATIONS?



By automating our processes and collecting information up front, we strive to
provide faster, more consistent responses to your concurrent review. In some
cases, we may be able to provide an initial concurrent review approval during
the initial transaction. Automation via our portal will help reduce or eliminate
the number of follow-up communications currently needed to make an informed
medical necessity determination.

Note: Emergent inpatient admissions do not require preauthorization. The
information requested and the approvals given are for the concurrent review of
the inpatient stay.


WHEN WILL THE NEW AUTOMATION BE AVAILABLE?



You should start to see requests for additional information to start the
concurrent review process in April 2023.


HOW WILL THE AUTOMATION WORK?



Submit notifications through the provider portals following the same steps you
use today. At the end of applicable transactions, you may be prompted to provide
additional information. You will be taken to a new set of screens where you
will:

 * Check off boxes next to statements that apply to your patient’s needs.
 * Click icons to open windows where you can provide additional details.
 * Upload additional documents if you have not done so earlier.


ATTACHING DOCUMENTS TO TRANSACTIONS


ARE THERE SPECIFIC FORMATS FOR ATTACHMENTS THAT MUST BE USED (E.G., PDF, TIFF,
JPEG)?



You will only be allowed to attach a document in one of the following formats:
doc, docx, pdf, xls, ppt, jpg, jpeg, png, bmp, gif, and txt.


CAN MORE THAN ONE DOCUMENT BE ATTACHED?



You can upload up to five (5) attachments at a time. If you need to send us more
than five (5) items, please send them in batches.


IS THERE A SIZE LIMIT TO ATTACHMENTS?



Yes, twenty-five (25) MB per file for preauthorization requests and
notifications, up to five (5) attachments.


CAN A DOCUMENT BE REMOVED IF ATTACHED TO THE WRONG CASE, MESSAGE, TRANSACTION,
ETC.?



The attachment can only be removed BEFORE the user selects “Upload.” Once the
user selects “Upload,” the attachment cannot be removed.


OBTAINING INFORMATION FROM THE PORTAL


WILL REFUND LETTER REQUESTS BE SENT VIA THE PORTAL?



No. Refund letter requests will not be sent by, nor be available in, the portal.


DO WE HAVE AN OPTION TO DOWNLOAD OR PRINT A TRANSACTION CONFIRMATION PAGE?



The portal itself does not have a printing function. To download or print a
webpage, use the browser’s print function.


GRIEVANCES & APPEALS


CAN I FILE A GRIEVANCE OR APPEAL USING THE PORTAL?



Yes. You may use the “Ask a Question” button to submit a grievance or appeal a
claim denial through the Message Center. Please use the Grievances and Appeals
category so the issue can be routed to the correct staff. You will be able to
upload supporting documentation. See questions on Attaching Documents to
Transactions for details.


WILL I BE ABLE TO UPLOAD CORRECTED CLAIMS THROUGH THE PORTAL?



You will be able to upload documents in support of corrected claims but the
actual process of claims correction will need to continue as it is today.


SUPPORT


HOW DO I RECOVER MY USERNAME OR RESET MY PASSWORD?



You can always recover your username or reset your password if you have
forgotten it by clicking on the “Forgot Username?” or “Forgot Password?” link on
the Provider Portal Sign In page.

You will have to provide us with the email address on the account, and we will
either remind you of your username or provide you with instructions via email to
reset your password.

In order for us to be able to help you with this request, it is very important
that you always keep the email address associated with the account up to date
with an email account you have access to.


WHO DO I CONTACT IF I CANNOT SIGN IN TO THE PORTAL?



Please first contact the Office Manager/Administrator for your organization.
 

If you still have an issue, contact our Provider Customer Service, Monday to
Friday from
8 a.m. to 6 p.m.:
 

EmblemHealth: 866-447-9717
ConnectiCare Commercial: 860-674-5850 or 800-828-3407
ConnectiCare Medicare: 877-224-8230

EHJP58184/CCIJP58663 3/23




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Any information provided on this Website is for informational purposes only. It
is not medical advice and should not be substituted for regular consultation
with your health care provider. If you have any concerns about your health,
please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments
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