Emblem Frequently Asked Questions

About the Transition and Implications to Your HIP or Magellan Health Services Contracts

I am confused by the recent correspondence that I have received from EmblemHealth and Beacon Health Options. Can you explain these mailings and what I have to do?

Yes, several mailings have been sent to EmblemHealth and Beacon Health Options network providers.

EmblemHealth announced its affiliation with Beacon Health Options to its network providers through letters, Web postings and the summer 2011 edition of their provider newsletter, News&Notes. These notifications state that, in this affiliation, Beacon Health Options would administer the Emblem Behavioral Health Services Program.  Further, these communications explain that providers will be required to contract with Beacon Health Options in order to continue delivering services to EmblemHealth members as network providers.

As a result of the contract award, we sent invitation packets to EmblemHealth’s providers to expand our network. If you received this package, it is because you were not participating or not participating in all of Beacon Health Options’ lines of business in the State of New York.

Lastly, EmblemHealth has sent correspondence to all its participating providers amending their contracts to meet current New York State regulatory and compliance standards. The EmblemHealth contract will apply until the Emblem Behavioral Health Services Program administered by Beacon Health Options goes into effect.

When will Beacon Health Options become the benefit administrator for Emblem Behavioral Health Services?

Effective January 1, 2012 Beacon Health Options will administer the Emblem Behavioral Health Services Program.

EmblemHealth will be sending the behavioral health providers in their HIP and GHI HMO networks additional information that will include the effective date of the transition. Also, Magellan Health Services will be communicating to providers in their network who have provided care to GHI HMO members.

(GHI and HIP are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.)

Which EmblemHealth members are affected by the transition to Beacon Health Options?

Starting early next year, members of GHI HMO plans and of plans underwritten by HIP Health Plan of New York (HIP) and HIP Insurance Company of New York (HIPIC), as well as ASO members managed by Vytra Health Management Systems (VHMS) will have their behavioral health services administered by Beacon Health Options.

At the present time, members of PPO plans underwritten by Group Health Incorporated (GHI) have their behavioral health services administrated by Beacon Health Options. The expanded relationship with Beacon Health Options will not impact this program.

(GHI and HIP are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.)

Which EmblemHealth members are not affected by the transition?

The transition to Beacon Health Options does not apply to members who:

  • Do not have a behavioral health benefit
  • Members who have the Montefiore logo on the lower left corner of their ID cards and are being treated by a provider in the Montefiore network are not required to change providers. They also have the option to use Beacon Health Options network providers.

If I treat a HIP member who has a Montefiore logo on their ID card, will they have coverage as part of Emblem Behavioral Health Services Program administered by Beacon Health Options?

To treat a HIP member who has an ID card with the Montefiore logo, you must be a participating provider in either the Beacon Health Options or the Montefiore network for the member’s coverage under the Emblem Behavioral Health Services Program administered by Beacon Health Options to apply.

Members who have the Montefiore logo in the lower left corner of their ID card, whether in treatment or not, will continue to access behavioral health providers in the Montefiore network. These members also may, at their option, utilize the Beacon Health Options network.

Beacon Health Options providers who provide care to a member with the Montefiore logo on their ID card must submit claims to Beacon Health Options. Please note that utilization management functions for behavioral health services for these members, including prior approval, will continue to be performed by Montefiore.

What is the transition benefit plan for members whose providers are not credentialed/contracted with Beacon Health Options and/or CHCS IPA (HMO) network prior to the transition date?

Members who are in active treatment with a provider who has declined network participation or has not completed the necessary application, credentialing and contracting processes with Beacon Health Options, may elect to continue treatment with the provider for a period up to 90-days provided that the provider accepts EmblemHealth’s or Magellan Health Services’s (as applicable) fee schedule and continues to follow their policies and procedures.  If a patient chooses to remain under the care of a non-participating provider after the transitional 90-day period, services will not be covered as in-network and your patient may be responsible for all or a portion of your charges, depending on the plan.

I am currently seeing GHI PPO members. How does this impact me?

There is no change to your participation status with GHI PPO members due to this business expansion.

How does the transition affect my contract with Magellan Health Services?

Until the transition occurs, Magellan Health Services administers behavioral health services for GHI HMO members. Please contact Magellan directly at 1-800-788-4005 to discuss your contract with them.

How does the transition affect my contract with HIP?

Once the transition occurs, your contract with HIP will become dormant. Once the transition date is effective, EmblemHealth will no longer be contracting directly with behavioral health providers.

Will members receive new ID cards or ID numbers?

  • GHI HMO ID cards: New ID cards will be issued to GHI HMO plan members in mid-December, 2011. The cards will include the updated Emblem Behavioral Health Services Program Customer Service phone number: 1-888-447-2526.
  • All other ID cards: New ID cards will be issued to all other plan members as groups renew throughout the year. The Emblem Behavioral Health Services Program Customer Service phone number (1-888-447-2526) will not change on the cards, but the name of the program and claims address will be updated on reissued ID cards.
  • ID numbers: There will be no change to any member ID numbers.

Beacon Health Options Network Participation (Contracting and Credentialing)

I currently participate with Beacon Health Options. What do I have to do?

To participate with all lines of business in the State of New York under Beacon Health Options, you are required to have both a Beacon Health Options Practitioner or Facility Agreement and a CHCS IPA (HMO) agreement.  Beacon Health Options has issued correspondence to our participating providers with instructions regarding the CHCS IPA (HMO) Agreement and Beacon Health Options Agreements. Please follow the instructions provided in the correspondence and return any required documents within 10 business days of receipt.

What will happen if I have a Beacon Health Options CHCS IPA (HMO, Medicare and/or Medicaid) Agreement but elect not to sign a Beacon Health Options Practitioner or Facility Agreement?

You will only be considered a network provider for HMO, Medicaid Managed Care, Family Health Plus, Child Health Plus and Medicare Advantage lines of business.

I do not participate in any of the Beacon Health Options networks. How do I join?

To ensure member access to treatment and to minimize potential care disruption, Beacon Health Options has extended invitations for network participation. We encourage you to adhere to the instructions and processing time frames that were outlined in the letter.

What are the fee schedules for the Emblem Behavioral Health Services Program administered by Beacon Health Options?

The fee schedules were enclosed in the invitation to join the Beacon Health Options network. The fee schedules detail the payments (by CPT code and licensure) that you will receive for providing services to the EmblemHealth membership.

If you are already participating in Beacon Health Options Commercial network, you should have received a letter extending network participation for the Emblem Behavioral Health Services Program administered by Beacon Health Options Program. Enclosed with that correspondence was the CHCS IPA (HMO) Agreement. The fee schedules that apply to our HMO client benefit plans in New York are included as Exhibit A of that Agreement.

My current Outpatient fee schedule is more favorable than Beacon Health Options. With whom do I discuss the fee schedule? (FOR INDIVIDUAL PRACTITIONERS/OUTPATIENT CLINICS/GROUPS ONLY)

Beacon Health Options fee schedules for outpatient services are reviewed routinely and at present are determined to be competitive with that of other companies with similar HMO business across the United States. In general, the fee schedules for outpatient services are non-negotiable. If you have any questions, please contact the Provider Service Line at 1-800-235-3149 and ask to speak with a Provider Service Representative.

Our current Inpatient/Alternative Levels of Care fee schedule is more favorable than Beacon Health Options. With whom do I discuss the fee schedule? [FOR INPATIENT FACILITIES ONLY]

Beacon Health Options reimbursement schedules for inpatient services have been determined to be   competitive with other companies with similar HMO business across the United States.  In general, the inpatient reimbursement schedules are non-negotiable. If you believe that your fee schedule needs to be reviewed, please contact our Contracting Department at 1-212-560-7729 and request to speak with a Contract Development Director.

For issues not related to your fee schedule, please contact the Provider Service Line at 1-800-235-3149 and ask to speak with a Provider Service Representative.

Do I have to be credentialed by Beacon Health Options?

Yes, all non-participating providers must be credentialed by Beacon Health Options in order to participate in the Beacon Health Options network.

I just completed my credentialing/recredentialing with EmblemHealth. Would Beacon Health Options accept the materials I have just submitted to EmblemHealth rather that my completing a new application?

Unfortunately, no. As an NCQA accredited organization, Beacon Health Options requires specific information and all providers must be credentialed by us in order to be considered as an in-network provider.

Beacon Health Options Online Services

What online services does Beacon Health Options offer?

Beacon Health Options has online services to provide added convenience for our members and providers.

ProviderConnect is a self-service tool available 24/7 that gives you access to the following features: single and multiple electronic claims submission, claims status review (for both paper and online submitted claims), eligibility status, your provider practice profile, and correspondence (which includes authorizations). Find more information about ProviderConnect on www.BeaconHealthOptions.com.

Can I submit my claims electronically to Beacon Health Options?

Yes, Beacon Health Options encourages electronic submission. CMS 1500 and UB-04 electronic submissions are accepted according to guidelines contained in the Beacon Health Options EDI materials found on www.BeaconHealthOptions.com. If you are interested in electronic claim submission, please contact our Beacon Health Options Electronic Claims Specialist at 1-888-247-9311. We strongly encourage providers to submit claims electronically for the efficiencies gained by both providers and in claims processing.

What paper forms can be used for claims submission?

Providers are required to bill on standard CMS 1500 and UB-04 forms. Red ink forms should be used as these can be scanned, which expedites the claim entry into the claims system. The UB-04 Form can only be used for inpatient and alternative levels of care for mental health and substance abuse, not outpatient professional mental health services. The CMS 1500 form should be used for outpatient professional services.

Does the Beacon Health Options electronic claims format work with other claims clearing houses?

Beacon Health Options accepts HIPAA compliant 837P and 837I formatted files directly from providers, and from some clearing houses.  All submitters, providers and clearing houses, must be registered to submit claims electronically. If you utilize the services of a third party vendor, please ask them if they are registered. Please note: Beacon Health Options does not reimburse for provider expenses associated with electronic claims submission. If you wish to register for electronic claims submission, please visit the provider section on Beacon Health Options’ website at www.Beacon Health Options.com. For any other electronic claims submission questions, please contact our Beacon Health Options Electronic Claims Specialist at 1-888-247-9311.

When Beacon Health Options authorizes care, is the authorization an automatic guarantee of payment for services rendered?

No, authorization of services is not a guarantee of payment. Payment depends on a number of factors including member eligibility, provider contract status, and benefit limits at the time care is rendered and the claim is processed.

As an individual practitioner billing outpatient services, do I need to include the provider number on my claims?

We strongly recommend billing electronically, either via EDI or our web-based direct claim submission. If submitting on paper, outpatient professional services must be billed on a CMS-1500 form and include the billing and rendering providers’ NPI, and Tax Identification Numbers. Please note: Billed lines are limited to 10 per claim form.

CMS-1500 required fields:

  • Insured’s ID number from their ID Card
  • Patient’s name as it appears on their ID Card
  • Patient’s birth date and gender
  • Insured’s name
  • Patient’s address, city, state, zip code and telephone number
  • Patient’s relationship to the insured
  • Insured’s address, city, state, zip code and telephone number
  • Patient status — married/single
  • Other Insured’s name, if there is other coverage
  • Is the patient’s condition related to: Employment? Auto accident? Other accident?
  • Insured’s date of birth — if there is other coverage
  • Is there another health benefit plan?
  • Diagnosis or nature of illness or injury — ICD-9 diagnosis code(s) — use HIPAA-compliant codes
  • Dates of service
  • Place of service
  • Procedures, services or supplies — use HIPAA Compliant CPT/HCPCS codes
  • Procedures, services or supplies modifier
  • Diagnosis pointer
  • Charges
  • Days or units
  • Rendering Provider NPI
  • Federal Tax ID number and type
  • Total charge
  • Signature of physician or supplier, including degrees or credentials
  • Name and address of facility where services were rendered
  • Physician’s/supplier’s billing: name, address, zip code and telephone number.
  • Billing Provider’s NPI

In addition, please visit www.BeaconHealthOptions.com for a complete list, instructions for completing the CMS 1500 form, and more information on proper billing procedures.

As a facility, how do I bill professional services?

Outpatient professional services must be billed on a CMS-1500 form. Please see the required fields listed above.

As a facility, how do I bill nonprofessional services?

Facility services may be billed electronically using the HIPAA-compliant 837I form. If billing on paper, inpatient services and alternate levels of care (e.g., PHP and IOP) must be billed on a UB-04 form.

UB-04 required fields:

  • Facility Service address
  • Pay-to-name and address
  • Billing Provider NPI
  • Provider name, address and telephone number
  • Type of bill
  • Federal Tax ID Number
  • Statement covers period “From” and “Through”
  • Patient’s name (last, first name, middle initial) as it appears on ID Card
  • Patient’s address
  • Birth date
  • Sex
  • Marital status
  • Admission date
  • Admission hour
  • Source of referral for admission
  • Discharge hour
  • Patient status
  • Responsible party name and address
  • Revenue code
  • HCPCS code
  • Service date
  • Service units
  • Total charges
  • Payer
  • Release of information certification indicator
  • Assignment of benefits
  • Insured’s name (last, first name, middle initial)
  • Insured’s ID number from ID Card
  • Patient’s relationship to insured
  • Group name
  • Diagnosis and procedure code qualifier (ICD version indicator)
  • Other diagnosis codes/present on admission indicator (POA)
  • Attending provider names and NPI
  • Principal diagnosis code
  • Admitting diagnosis code
  • Attending physician identification number
  • Provider representative
  • Date

How soon will I receive a claims payment?

If the provider submits a clean claim electronically within timely filing limits, compensation to the provider shall be at the rates specified in the fee schedule and paid to the provider within 30 days for electronic claim submission and 45 days for claims submitted on paper.

What are Payformance and PaySpan Health?

Payformance is a vendor that partners with Beacon Health Options to deliver an electronic funds transfer (EFT) solution to our providers.

PaySpan Health is the software that Payformance uses for online registration for EFT. PaySpan Health is a multi-payer adjudicated claims settlement service that delivers electronic payments and electronic remittance advices based on your provider preferences. With PaySpan Health, you stay in control of bank accounts, file formats, and accounting processes.

What is the unique registration code number that PaySpan Health requests and how do I obtain it?

Your unique registration code is the registration number that Beacon Health Options supplies to providers for enrolling in PaySpan Health. If you do not have the letter with your unique registration code, please send an e-mail to CorporateFinance@beaconhealthoptions.com  and include the following information:

  1. Your Beacon Health Options pay-to-vendor number (PIN)
  2. Your Tax Identification Number (TIN) or your Social Security Number (SSN)

You will receive an e-mail with your registration code letter within three business days of your request.

Note: If you recently received a payment from Beacon Health Options, your unique registration code will be located on the check stub after the marketing caption.

Additional questions about PaySpan can be addressed by calling PayFormance Customer Service at 1-877-331-7154, Monday-Friday 7 a.m. – 9 p.m. ET

Clinical, Authorization and Quality Services Provided by Beacon Health Options

What are the operating hours of the Beacon Health Options Clinical Department?

Licensed clinicians are available 24 hours a day, 7 days a week and 365 days a year. It is imperative that, in the event of emergent care, the provider contact Beacon Health Options as soon as possible, but no later than 24 hours after the emergent contact/session/admission.

As an inpatient facility, when should an authorization of an admission be requested?

Pre-certification is required for all elective inpatient services. You should call Emblem Behavioral Health Services Program administered by Beacon Health Options at the number listed on the back of the member’s health insurance card to review the clinical information and available services. Our phone lines are open 24 hours a day, 7 days a week and 365 days a year.

What are the prior approval requirements for outpatient services?

Prior approval is not required for routine outpatient services. Beacon Health Options will, however, reach out to providers when routine services are accessed excessively so as to no longer be considered “routine.”

Prior approval is always required for the following non-routine outpatient services:

  • Partial hospitalization
  • Inpatient behavioral health treatment
  • Ambulatory detoxification treatment
  • Outpatient ECT (electro-convulsive treatment)
  • Neuropsychological testing
  • Psychological testing
  • Outpatient and intensive outpatient substance abuse treatment

When will Beacon Health Options become responsible for claims adjudication?

Outpatient Services: Beacon Health Options is responsible for adjudicating claims for dates of service on or after the start date of the program.

Inpatient Services: Beacon Health Options is responsible for adjudicating claims for inpatient dates of service when a member is admitted to an inpatient unit on or after the start date of the program. If a member is admitted to an inpatient unit before the start date of the program, EmblemHealth/Magellan will adjudicate the claim(s). Beacon Health Options will first become responsible for adjudicating claims for the member’s care post-discharge or transfer to an alternate level of care.

Who is responsible for members admitted to an inpatient medical unit who also have behavioral health issues that need to be treated?

Members admitted to a medical floor are the responsibility of EmblemHealth. Authorization is required by EmblemHealth Prior Authorization department and claims must be submitted to EmblemHealth.

If the member is transferred to a psychiatric or substance abuse unit (except for medical detoxification), Beacon Health Options will need to review, authorize the care, and process the claims. Claims for dates of service in the psychiatric or substance abuse unit should be submitted to Beacon Health Options.

What is the process for continuing outpatient care?

For members seeing Beacon Health Options providers, nothing is required. Beacon Health Options manages outpatient care via outlier management review. Beacon Health Options will notify you if a treatment plan is required.

For members seeing an EmblemHealth or Magellan Health Services provider who is not joining the Beacon Health Options network, a 90-day transition benefit is allowed if the provider accepts EmblemHealth’s or Magellan Health Services’ (as applicable) fee schedule and continues to follow their policies and procedures.

The member’s benefit plan will define whether or not the member’s benefit plan provides coverage for out-of-network providers. To see a copy of the member’s benefits, you may use the secure provider Web site at www.emblemhealth.com.

Claims Submission

Does the claims submission process change if I am currently contracted as a Beacon Health Options GHI Behavioral Management (BMP) provider?

For providers currently contracted with Beacon Health Options GHI BMP, the claims process does not change and will continue to be processed by EmblemHealth/GHI.

Where do I submit my claims prior to the effective date of the transition?

EmblemHealth will be responsible for reimbursement of elective inpatient admissions that received prior approval and emergency room admissions for which there was appropriate notification to the plan commencing prior to the transition date and any other services rendered prior to the transition date; therefore, please submit claims with dates of service prior to the transition date to the EmblemHealth address indicated on the member’s ID card.

Non-authorized claims submitted by non-participating providers are subject to the member’s specific plan cost sharing (co-pays and/or coinsurance) and penalties. If the member’s plan does not have out of network benefits, non-participating provider claims may be denied.

Where/how do I submit my claims to Beacon Health Options?

Beacon Health Options has a is a self-service tool, ProviderConnect , that enables single and multiple electronic claims submission as well as claims status review (for both paper and online submitted claims). Find more information about ProviderConnect on www.BeaconHealthOptions.com.

Beacon Health Options accepts CMS 1500 and UB-04 electronic submissions according to guidelines contained in the Beacon Health Options EDI materials found on www.BeaconHealthOptions.com. If you are interested in electronic claim submission, please contact our Beacon Health Options Electronic Claims Specialist at 1-888-247-9311. Please note: Beacon Health Options does not reimburse for provider expenses associated with electronic claims submission.

We strongly encourage providers to submit claims electronically for the efficiencies gained by both providers and in claims processing. If, however, a paper claim needs to be sent in (such as for a corrected claim), please send it to:

Beacon Health Options
PO Box 803
Latham, NY 12110

On or after the transition date, where do I go to have a claim question/issue resolved?

Please visit us online at www.BeaconHealthOptions.com to check and review a claim status or call 1-888-447-2526.