Provider Help and Support | EmblemHealth

You can find EmblemHealth medical policies in Clinical Corner. These medical policies reflect some of the information we consider when determining the medical necessity of certain services or supplies.

You can:
  • submit electronic claims to EmblemHealth using the Payor IDs listed in the Claims Contacts chart in the Directory chapter of the provider manual.
  • submit paper claims (CMS-1500 forms) to the addresses listed in the Claims Contacts chart, unless otherwise indicated on the member’s ID card.

For more information please click here.

  1. Sign into our provider portal.
  2. Select Claims/Checks from the left navigation.
  3. To search claims for the past 18 months:
    1. Pick the Member’s Plan (EmblemHealth, GHI, or HIP).
    2. Select Category (e.g., medical, hospital) from the drop-down menu.
    3. Select Provider(s) from the drop-down menu.
    4. Enter at least one piece of information, such as service date, patient ID, or claim number.
    5. Select Search Claims to view claims on screen or Download Results to view claims in an Excel report.
  4. The results page will display claims activity using the parameters you specified.
  5. Select Claim # to view more details on a claim.
  6. After viewing claim details, you may choose to Print Claim or go Back to Claims List.
  7. If you wish to contact us about a claim, select  Contact EmblemHealth About This Claim, write a brief message, attach a file if needed, and click Send Message. The claim information prepopulates.
  8. If the claim has been paid and a check number is available, select Check # for check details and a copy of the check/remittance if available. For claims paid via EFT/ERA, go to PNC Remittance Advantage at rad.pnc.com.
  9. After viewing check details, you may choose to Print or go Back to Claim Details.
    • Note: You may also select the Search Checks tab to search by check.

Religio-Cultural Competency

Properly addressing religion is a key element of providing patient-centered care and improving health outcomes and patient and family satisfaction. That’s why we partnered with the Tanenbaum Center for Interreligious Understanding, a secular nonprofit organization dedicated to overcoming religious bias and intolerance, to create resources that help medical practitioners understand how religious beliefs and practices intersect with medical science. For more information, please see the Cultural Competency Continuing Education and Resources section of our Learning Online page.

Language Line: Interpreter Service

Free multi-language interpreter service is available to assist providers and their patients. Services are available in over 200 languages, including English, Spanish, Chinese Mandarin, Chinese Cantonese, Tagalog, French, Vietnamese, German, Korean, Russian, Arabic, Italian, Portuguese, French Creole, Polish, Hindi and Japanese. To access an interpreter, providers may call 1-866-447-9717 and a Provider Customer Care Advocate will assist you.

Provider Relations Identification System (PRIS) Number is an assigned number that distinguishes each provider’s participating service location. Each participating service location, credentialed with EmblemHealth (HIP) receives a PRIS Number. 

If a provider does not know their PRIS Number they may contact an EmblemHealth Customer Care Provider Advocate at 866-447-9717 or they may refer to the provider directory by following the directions below:

  1. Go to Find a Doctor on emblemhealth.com
  2. Scroll down to one of the Prime Network plans in which you participate
  3. Click Providers, then Search on the dropdown that appears.
  4. Enter the provider’s name (or whatever criteria you have) and click Search at the bottom.
  5. Click on the providers name to see more information associated with their practice, including their PRIS number (which is also referred to as a Directory number).
  6. This page also includes plans and networks in which the provider participates. If something is wrong, you should correct it. To do so, please visit our Update Directory page.

The most efficient, safe and streamlined way to do business with EmblemHealth is through our secure website. It also is the quickest, most cost-effective and most environmentally friendly way to receive and send information. So, if you haven’t already, please sign up for secure access today. Just go to our Secure Portal Access page and click Register. Complete the required fields.

Note: HIP providers have a Provider Number (aka PRIS#) for each of their locations and must register each Provider Number separately. GHI providers have only one Provider Number but must register for each of their TINs separately. 

Need help finding your provider number(s)?

  • Go to Find a Doctor on emblemhealth.com
  • Scroll down to one of the Prime Network plans in which you participate
  • Click Providers, then Search on the dropdown that appears.
  • Enter the provider’s name (or whatever criteria you have) and click Search at the bottom.
  • Click on the providers name to see more information associated with their practice, including their PRIS number (which is also referred to as a Directory number). If you are a HIP provider and have multiple locations, click “See Other Locations” and then “See Details” for each location to gather all of your Provider Numbers.
  • This page also includes plans and networks in which the provider participates. If something is wrong, you should correct it. To do so, please visit our Update Directory page

Need help registering?

  • If you are a HIP provider, you need to register each office location separately, using your location-specific Provider Numbers: If you have three locations, you will need to complete the registration process three times. 
  • If you are a GHI provider, you need to register each TIN used to submit claims separately. This meant if you have two TINs, you will need to complete the registration process two times. Use the same Provider Number for each registration. 
  • If you are both a HIP and GHI provider, please follow the instructions in the first two bullets. 

Once registered, you can:

  • Check your network participation.
  • Update your practice information.
  • Set the level of access for your staff.
  • Appoint a staff member to act on your behalf.
  • Check member benefits and eligibility and manage referrals and prior approval.
  1. Sign into our provider portal.
  2. Select Benefits/Eligibility from the left navigation.
  3. To search by patient ID number, enter up to ten (10) ID numbers separated by commas and select Search. You can also search by patient last name and date of birth. (For members in HIP-underwritten plans, you can also check eligibility for dates in the past.)
  4. The results page lists member information, such as plan effective date, plan name, and plan status. You can also view hospital or dental eligibility.
  5. Select Details to view the member’s demographic information, managing entity, and primary care physician.
  6. Select Benefit Details or Benefit Summary to view a summary of benefits. For certain limited benefits, such as outpatient speech, occupational, and physical therapy, select Benefit Limits to see the patient’s benefit limit and the benefits remaining in the current coverage year.

For EmblemHealth benefit plans that require referrals, the referral must be made to a network specialist in the member’s benefit plan. You will be able to check specialist participation, one you initiate the referral request.

  • Sign in to our secure portal with your PRIS number (which is also referred to as a Directory number in Find a Doctor tool)
  • Select a service type.
    • Search for the specialty provider using either the specialists PRIS number, if known, or by entering general information such as the provider’s area of specialization and the members benefit plan information. This will provide you with a list of providers that participate in the members benefit plan. Select a provider and continue with creating the referral.
  • The system will guide you through the process based on the member's benefit plan.
  • To check the status of a referral, search by the member's ID number or by trace/authorization number.

Refer to the “How Obtain Prior Approval” section of the Directory chapter of the Provider Manual.

We recommend that you periodically review the information we have on file for you. To do this, sign in to our secure website and select "Provider Profile" or "Practice Profile" from the left navigation panel.

You may also visit our Update Directory page for guidance and a form for submitting updates (provided you are not credentialed through a delegated vendor. In that case see your credentialing coordinator).

Helpful tip: The Provider/ Practice Profile screen also includes information about the networks you participate in. You must accept a patient’s benefit plan if the network shown on the member’s ID card, on the eligibility details screen on our secure provider website or shared through our IVR system, matches one of your participating networks. According to our standard contracting guidelines, if you are in a network, you may see members with any benefit plan associated with that network.

Keeping your information current ensures we send your claims payments and other important correspondence to the correct address. It also helps our members contact you at your current location. If you don’t have access to a computer, please fax any changes to our Provider Modifications team at 1-877-889-9061. You may also mail your changes to:

Provider Modifications Team
55 Water Street,
6th Floor,
New York, New York, 10041-8190

If you have questions about your network participation, please sign in to our secure provider website and go to our Message Center. Select “General Information” as the category from the drop-down menu on the “Ask a Question” page. Thank you for your partnership with EmblemHealth.

EmblemHealth has dedicated a web page of useful member materials on our Live Well site so your EmblemHealth patients can manage their care and keep their costs down.    

Providers should verify member eligibility as outlined in the chart below.

Confirm Member Eligibility

Provider Network

Instructions
(Choose one of the bulleted options)
Have your TIN ready before calling the IVR system

Select Care Network

Prime Network

Bridge Network

Enhanced Care Prime Network

VIP Prime Network

  • Check eligibility at emblemhealth.com
    • PCPs may also check their Panel Reports
  • Speak to a representative or call the IVR phone system at 866-447-9717
  • Providers with eMedNY access may check the enrollment of their Medicaid members on ePACES.
CBP, National & Tristate Networks

Network Access Network
  • Check eligibility at emblemhealth.com
  • Speak to a representative or call the IVR phone system: 
    NYC: 212-501-4444 
    Outside NYC: 800-624-2414
Medicare Choice PPO Network
  • Check eligibility at emblemhealth.com
  • Speak to a representative or call the IVR phone system at 866-557-7300
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