Medicare AdvantageAdministrativeMedium impact
April 2019 In The Know
EmblemHealth·NY · Pathology, OB-GYN, General Surgery·Provider News
We identified it
Jun 20, 2026
Summary
EmblemHealth has implemented new payment policies for Surgical Pathology CPT codes and updated billing rules for dual-eligible Medicare members. Providers are prohibited from balance billing dual-eligible HMO SNP members for Medicare cost-sharing and must obtain signed consent forms for Medicaid hysterectomy/sterilization procedures.
Action Required
Immediately: Stop balance billing dual-eligible HMO SNP members (EmblemHealth VIP Dual Group, EmblemHealth VIP Dual, EmblemHealth Affinity Medicare Ultimate, EmblemHealth Affinity Medicare Solutions, and ArchCare Advantage) for Medicare deductibles, coinsurance, or copayments. Update billing system to bill Medicaid as secondary payer and accept Medicare/Medicaid payments as payment in full. For Medicaid hysterectomy/sterilization procedures, ensure signed consent forms are obtained and submitted with claims to prevent processing delays.