New Oscar Health Insurance Contract

Oscar Health Insurance, the New York-based health insurance start-up with an emphasis on simplicity, has signed a contract with Montefiore that will include all members of the Montefiore IPA in its network.

The company targets young, computer-savvy consumers with an easy-to-navigate online application and a menu of additional benefits and incentives.

Members of all of Oscar’s individual, small group, commercial EPO and New York State of Health plans in New York City and Westchester and Rockland counties will be covered by the contract, which will be effective January 1, 2017.

Full details of the contract and applicable rates will be sent to all eligible providers within the next few weeks. Training on Oscar’s provider portal and claims filing, eligibility verification and authorization procedures will be offered.


Time Frames for Urgent and Non-Urgent Utilization Review Requests

To enable us to serve you and your patients better and comply with all regulatory requirements, use the terms Urgent, STAT or ASAP, etc. only on Utilization Review requests that meet the definition and criteria cited below. If the service you need is not truly urgent, please remove these terms from your request/fax cover sheet.

If you include the words Urgent, STAT or ASAP on a Utilization Review request, you trigger a process that has stricter regulatory requirements for determinations, including the time frame as well as verbal and written member and provider notifications.

When is it appropriate to use Urgent, STAT or ASAP on a request?

Under 2016 NCQA Standards for Utilization Management – UM 5 Timeliness of UM Decisions—an Urgent Request is “A request for medical care or services where application of the time frame for making routine or non-life threatening care determinations:

  • Could seriously jeopardize the life, health or safety of the member or others, due to the member’s psychological state, or
  • In the opinion of a practitioner with knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request.”

CMO adheres to the following NCQA UM 5 Element A time frames for timeliness of non-behavioral healthcare decision making:

  • Urgent pre-service decisions: within 72 hours of receipt of the request and all necessary information
  • Non-urgent pre-service decisions: within 14 calendar days of receipt of the request and all necessary information

CMO’s usual time frame for making a decision on non-urgent pre-service requests is 3 business days if all information is received.


EmblemHealth ePASS Program Training Opportunities

The Electronic Patient Assessment Solution Suite (ePASS) program can be used by MIPA providers to access a supplemental clinical profile and complete a compliant medical SOAP note for patients identified by EmblemHealth

The ePass program is designed to ensure that Emblem Medicare members in your practice receive their 2016 clinical assessment and that you are able to identify and close gaps in clinical documentation, care management and healthcare data accuracy.

You are eligible to receive an incentive of $150 for each Medicare member assessment and $40 for each Medicaid member assessment you enter in the ePASS system for targeted Emblem patients seen by you through December 31, 2016.

If you are not yet using the ePASS system, are experiencing any challenges using it or would like additional information about it, Inovalon, the company that administers ePASS for Emblem, will offer a webinar every Thursday at 3 p.m. between now and December 29, 2016, that provides a practical overview of ePASS. The session typically takes 30 minutes followed by time for questions.

We encourage you to register in advance by sending an email to with your name, organization, contact information and the date of the webinar you wish to attend.

The following information can be used to join the ePASS webinars:

• Teleconference: Dial 1-888-850-4523 and enter access code: 693 680

• WebEx: Visit and enter meeting number: 748 514 647

• Once you join the call, live support is available at any time by dialing *0

If you have any questions about the ePASS program, feel free to contact the CMO Provider Relations department at 914-377-4477.


Coding for CVA, MI and Angina in the Outpatient Setting

Accuracy and specificity in diagnosis coding and medical documentation are critical to obtain a clear picture of all current medical problems for your patient.

The Medicare Hierarchical Condition Category (HCC) risk adjustment model is structured on severity of illness, with more severe diagnoses carrying the highest overall risk score. Documentation that conveys the current level of acuity or chronicity for each diagnosis will ensure appropriate funding each calendar year. Two conditions that are frequently miscoded in the outpatient setting are CVA and MI.



AAPC risk adjustment guidelines state: “When coding for a CVA, it is important that the active CVA code (I63.50) is only used when the CVA is occurring and up to discharge for the treatment of the stroke. Once a patient has been discharged for care of a CVA, personal history of a CVA is to be coded. It is also appropriate to code for any remaining deficits as a result of the CVA.”


Personal history of CVA is NOT in the Medicare HCC risk adjustment model.


Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits


Provider documentation must state the cause and effect relationship of the CVA to the residual condition. The following list of sequelae (late effects), are in the Medicare HCC risk adjustment model.

I69.131 to I69.159

Monoplegia, Hemiplegia or Hemiparesis upper / lower limb (right dominant, left dominant, right non-dominant, left non-dominant, or unspecified side) following nontraumatic intracerebral hemorrhage

I69.231 to I69.259

Monoplegia, Hemiplegia or Hemiparesis upper / lower limb (right dominant, left dominant, right non-dominant, left non-dominant, or unspecified side) following other nontraumatic intracerebral hemorrhage

I69.331 to I69.359

Monoplegia, Hemiplegia or Hemiparesis upper / lower limb (right dominant, left dominant, right non-dominant, left non-dominant, or unspecified side) following cerebral infarction

I69.831 to I69.859

Monoplegia, Hemiplegia or Hemiparesis upper / lower limb (right dominant, left dominant, right non-dominant, left non-dominant, or unspecified side) following other cerebrovascular disease

I69.931 to I69.959

Monoplegia, Hemiplegia or Hemiparesis upper / lower limb (right dominant, left dominant, right non-dominant, left non-dominant, or unspecified side) following unspecified cerebrovascular disease



A myocardial infarction described as acute, or within a period of 4 weeks or less, is classified as an acute MI. Acute and subsequent, ST and non-ST elevation myocardial infarction ICD-10 codes are in the HCC model but should only be coded as inpatient diagnoses.


MI codes are in the Medicare HCC risk adjustment model.

I 21.01 to I21.3

ST elevation (STEMI) myocardial infarction of anterior wall, inferior wall, other or unspecified sites.


Non-ST elevation (NSTEMI) myocardial infarction

I22.0 to I22.1

Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction of anterior wall or inferior wall


Subsequent non-ST elevation (NSTEMI) myocardial infarction

I22.8 to I22.9

Subsequent ST elevation (STEMI) myocardial infarction of other or unspecified sites

If the patient is being seen or treated after the 4 week period, provider documentation should indicate that the patient has a history of MI.


Personal history of MI is NOT in the Medicare HCC risk adjustment model.


Old myocardial infarction

Healed myocardial infarction

Past myocardial infarction diagnosed by ECG or other investigation, but currently presenting no symptoms



“Chest pain and angina are not interchangeable for coding. Chest pain is not a risk adjusted diagnosis because chest pain can be caused by many non-cardiac conditions. The provider should specify the type of angina, when known. Angina that is controlled on medication should be documented and coded.” *

Angina codes are in the Medicare HCC risk adjustment model.


Unstable angina (accelerated angina, crescendo angina, De novo effort angina, intermediate coronary syndrome, pre-infarction syndrome or worsening effort angina


Angina pectoris with documented spasm (angiospastic angina, Prinzmetal angina, spasm-induced angina or variant angina)


Other forms of angina pectoris (angina equivalent, angina of effort, coronary slow flow syndrome, or stenocardia)


Angina pectoris, unspecified (angina NOS, anginal syndrome, cardiac angina or ischemic chest pain)


If you have any questions please feel free to call the HCC coding department at 914-721-8563 or 914-721-8584 or send us an email:

* Gianatasio, Colleen. “Make the Most of HCCs, Part 1: Bolster documentation for commonly under-coded conditions.” AAPC Healthcare Business Monthly Dec. 2015: 40-41. Print.


Montefiore Diamond Care MLTC Plan Turning 3

Montefiore Diamond Care, Montefiore’s managed long term care (MLTC) plan, is approaching its third anniversary of providing care services to residents of Bronx and Westchester with a new website and the maximum possible quality score in the State’s annual survey of MLTC plans.

Montefiore Diamond Care serves Medicaid beneficiaries who have chronic health problems or a disability and require long-care services at home. Plan benefits include personal care services, social day care, environmental supports, dental and vision care, audiology, physical therapy and transportation to and from medical appointments.

Each member has a dedicated MLTC care manager who develops a plan of care with the member, his or her primary care provider and caregiver and who coordinates all long-term care services.

To be eligible for Montefiore Diamond Care, individuals must:

  • Be age 21 of age or older
  • Live in the Bronx or Westchester County
  • Be Medicaid eligible or have active Medicaid
  • Be able to safely be maintained at home or in a nursing home
  • Require long term care services for more than 120 days


To make a referral to Montefiore Diamond Care Plan, dial 1-855-556-6683 and press option 2 or email

Please visit Diamond Care’s new additional information.


Montefiore Asthma Center Services

Do you have a patient who has a severe case of asthma? Or recurrent need for systemic steroids/oral prednisone or other PMD concerns, such as refractory overuse of rescue inhalers?

If so, consider making a referral to the Montefiore Asthma Center.

The Montefiore Asthma Center serves adult patients at the Greene Medical Arts Pavilion (MAP) on the Moses Campus and pediatric patients at the Children’s Hospital at Montefiore (CHAM).

Since 2011, the Asthma Center has offered patients suffering from refractory, poorly controlled asthma a unique team approach that combines close collaboration between pulmonologists, allergists using advanced diagnostic and therapeutic techniques and educators, respiratory therapists and home health care services.

To ensure a comprehensive assessment of symptoms and possible medications, patients may receive cardiopulmonary exercise testing to check for exercise-induced asthma; inhalation challenge testing for diagnostic evaluation of complex asthma; sophisticated allergy/immunology testing, including full-panel skin testing and tests for a variety of inhaled and/or food allergens; and fiberoptic examination for direct exam of upper and lower airway problems.

Under the direction of Simon Spivack, MD, chief, Pulmonary Division, and David Rosenstreich, MD, chief, Allergy & Immunology Division, Asthma Center patients receive age-appropriate pulmonary and allergy evaluations requiring a minimum of 2-3 visits. This interdisciplinary approach provides a customized treatment program for treatment of asthma, sinusitis and rhinitis all at a single location.

Patients are prescribed the newest and most effective asthma medications available, and each patient is educated by Center physicians on how to take them. Patients are also counseled about allergen proofing their homes and how to avoid external triggers that can bring about an asthma attack.

The goal is to help patients improve the quality of their lives by promoting patient awareness and participation in the management of their asthma symptoms with resources, including from improved use of conventional agents and newer biologics, expertise and guidance so they better understand, manage and control their conditions.

Care plans are communicated to the primary care provider to eliminate or reduce visits to the emergency room and the need for corticosteroids as a method to control asthma symptoms.

Appointments for adults can be made by calling 866-633-8255.

Appointments for children can be made by calling 718-741-2450.

For urgent appointments, call Shauna Gay Taylor at 718-920-6370.