EmblemHealth Reimbursement Policy

Effective October 1, 2022, a new reimbursement policy for EmblemHealth and ConnectiCare was adopted to provide guidance on appropriate billing for services provided in a hospital/facility treatment room. 

EmblemHealthConnectiCare provides reimbursement for facility treatment room services directly related to procedures made on the same day of treatment. The Plan reimburses treatment room services if a specific, identifiable procedure has been performed. Another case is treatment rendered that is unrelated to inpatient or outpatient services provided within the contracted global reimbursement period. Treatment room services include ambulatory services that have been provided in the hospital utilizing a bed and periodic observation. To recover from such a procedure, you must use an intervention room instead of paying for an operating or recovery room. 

Following services are not available for treatments rooms:  

• Artificial limbs;  

• Diagnostic procedures, except those directly related to the performance of a surgical procedure; 

• Durable medical equipment (DME), for use in the patient’s home such as leg, arm, back or neck braces; 

• Laboratory; 

• Prosthetic devices;  

• Radiology. 

But there are some exclusions: 

• Emblem Health/ConnectiCare does not reimburse treatment room services rendered solely to carry out laboratory, radiology, or other diagnostic tests. 

• The Plan does not pay separately for services provided in the treatment room as part of the: 

     – Inpatient stay (within 24 to 72 hours of admission, by the patient’s overall reimbursement rate.); 

     – Outpatient minor surgical or medical procedure (within 24 to 72 hours, based on the total outpatient reimbursement rate.); 

     – Outpatient observation stay (within 24 to 72 hours, based on the total outpatient reimbursement rate.);  

     – Emergency room visit; 

     – Urgent care/Clinic visit; 

• The plan does not allow for reimbursement of office evaluation and management services when they are registered on an SMS 1450 (UB-04) with income code 0760/0761 (care rooms). Modifiers will not reverse the change. 

The removal, notice, and authorization policies and procedures applicable to the plan apply:

– An order is requested for processing room services; 

– A referral is required for treatment services that result in hospitalization. 

Benefits may vary from group to group and from contract to contract. Please refer to the appropriate Membership Agreement or Evidence of Coverage Enrollment Agreement for coverage to find out what coverage or benefits apply. 

Source: https://www.emblemhealth.com/