New Web Usage Requirements for GHI HMO
Starting November 1, 2012, the following Web usage updates will go into effect for the noted providers:
GHI HMO providers will be required to use www.emblemhealth.com or the provider IVR at 1-877-244-4466 to manage referrals and prior approval requests. Once a referral has been entered, it will automatically be linked to the claim the specialist submits. While specialists do not need to enter a referral number on their claims to ensure payment, they do need to confirm that a referral or applicable prior approval is in place on www.emblemhealth.com before rendering services.
Hospitals will be required to use www.emblemhealth.com to submit ER Admission Notifications for GHI HMO and HIP plan members. Submission of notice will automatically create an inpatient case in our system for those members managed directly by EmblemHealth. You will be able to follow the concurrent review status for cases managed by EmblemHealth’s Medical Management department (“HIP” will display as the Managing Entity online) through the Concurrent Review Status Report and through the Precertification/Prior Approval function of our secure provider Web site, available from the provider page of www.emblemhealth.com. Our system automatically routes notifications to Montefiore (CMO) or Health Care Partners (HCP), as appropriate, to trigger concurrent review. You will receive a time- and date-stamped confirmation showing when notice was given and which managing entity will handle the case.
If needed, you can back-date a referral up to 30 days.
If DX changes or you discover that an additional code applies, you do not need to update the DX code on the referral to ensure the referral is valid.
For specialists: Unless a service specifically requires prior approval, you do not need to request additional permission from the managing entity to render services that are within the scope of the referral.
GHI HMO hospitals and skilled nursing facilities (SNFs) will be given access to a Concurrent Review Status Report. ? report indicates concurrent review status for GHI HMO and HIP HMO members. It's posted to our Web site twice daily, around 9 am and 5 pm. Hospitals and SNFs who already receive the report for HIP members will see GHI HMO members added to it. Our experience with HIP-contracted facilities shows greatly reduced administrative time needed to facilitate discharge planning when the report is used to determine the concurrent review status.
A new prior approval CPT/HCPCS lookup tool will be added to www.emblemhealth.com. Use this tool to determine whether a CPT or HCPCS code requires prior approval based on your place of service. When you enter the member ID number, place of service, date of service and service code, the system will direct you to the prior approval requirement. If the EmblemHealth Medical Management team manages the member's care, you’ll be able to process the request right from that screen.
GHI HMO providers will have access to our role-based security tool on www.emblemhealth.com. This tool lets you control who in your practice/facility/organization can view your patients’ information. This change supports HIPAA compliance while aligning processes for GHI HMO and HIP HMO.
Authorizing your billing company to conduct business online
If you use a billing company, we encourage you to set them up as a "Billing Specialist" in the Security Application of our secure provider Web site, available from the provider page of www.emblemhealth.com. Doing so lets your agents check the disposition of claims, obtain copies of checks and remittances, and run downloadable claims reports from our Web site. In gaining security access to your claims and billing information, your agents will be able to review the status of submitted claims online, reducing time spent on the phone and on tracking the status of submitted claims. They will also be able to check eligibility, benefits, referrals and prior approvals online.